Health-Related Quality of Life in pre-dialysis patients with chronic kidney disease: the role of Big-Five personality traits and illness denial
BMC Psychology volume 10, Article number: 297 (2022)
Health-Related Quality of Life (HRQoL) in patients with chronic kidney disease (CKD) is significantly affected, regardless of the stage of the disease, as regards the physical, psychological and social functioning dimension. Big-Five personality traits can affect patients’ HRQoL and willingness to take treatment options. Illness denial consists of denial of negative emotions, resistance to change and conscious avoidance. Poorer HRQoL can predict a higher risk of hospitalization and mortality, and broadly a worse adjustment to the dialytic therapy. Thus, a clearer knowledge of the psychological variables associated with a worse HRQoL in the predialysis stage might improve the intervention planning. No study investigated illness denial and personality traits simultaneously. We investigated the role of illness denial and Big-Five personality traits in the domains of HRQoL in predialysis patients with CKD.
One hundred adults (mean age: 75.87 years) with CKD participated. The Kidney Disease Quality of Life Short form, the Italian version of Ten Item Personality Inventory Revised, the Illness Denial Questionnaire, and the State-Trait Anxiety Inventory Form-Y were administered.
Illness denial was associated with increased HRQoL related to symptoms/problems, effect and burden of CKD and cognitive functions domains, and it was a predictor of higher HRQoL in the last three domains mentioned above. Extraversion was related to better work status and sexual function; agreeableness was linked to elevated cognitive function, quality of social interaction and sexual function; conscientiousness was related to better sexual function; neuroticism was linked to improved cognitive and sexual functions; in the end, openness to experience was related to fewer symptoms and problems.
This is the first study which simultaneously assessed Big-Five personality traits and illness denial in different domains of HRQoL of CKD patients. Personalised psychological interventions aimed at improving HRQoL in this population might focus on specific illness denial processes and personality traits.
Health-Related Quality of life in chronic kidney disease
Health-Related Quality of Life (HRQoL) refers to the dimensions of functioning that are affected by one’s disease and/or treatment, including physical (the ability to perform activities of daily living, as well as physical symptoms resulting from the disease or treatment), psychological (ranging from severe psychological distress to a positive sense of well-being and cognitive functioning), and social functioning (quantitative and qualitative aspects of social relationships and societal integration) .
Chronic diseases (e.g., cancer, heart diseases, stroke, diabetes, bowel diseases, renal disease, and psychiatric diseases) have the potential of affecting and worsening the overall health of patients by limiting their capacity to have a good functional status and reducing the positive reinforcing outcomes of participating in valued activities and feelings of personal control [2,3,4,5,6,7].
Chronic kidney disease (CKD) is defined by indicators of kidney damage—imaging or proteinuria (i.e., albumin to creatinine ratio)—and decreased renal function—below thresholds of glomerular filtration rate (GFR) estimated from serum creatinine concentration—for at least three months .
The current recommendations by the Kidney Outcomes Quality Initiative  and National Institute for Health Excellence  are to use serum creatinine concentration to estimate glomerular filtration rate and transform it using the Chronic Kidney Disease Epidemiology Collaboration equation.
CKD compromises the physical—complications include anaemia, reduced red blood cell survival, iron deficiency, and mineral bone disease—and psychological health of patients, daily functioning, general wellbeing, and social functioning .
With a prevalence in the general population around 13%  CKD is associated with HRQoL across all the stages [13,14,15]. Poorer HRQoL is also related to a higher risk of developing end-stage kidney disease, which in turn predicts hospitalization and mortality, and falls as GFR declines . The more the kidney function worsens, the more the risk of death increases, and it’s largely attributable to death form cardiovascular disease and cancer .
Big-Five personality traits in CKD
The Big-Five model of personality integrates most of the evidence in personality psychology [18, 19] and assumes that individual differences in personality characteristics can be organised into five broad trait domains: extraversion (extravert people experience high levels of happiness and life satisfaction), agreeableness (individuals high in this trait are helpful, warm and emphatic), conscientiousness (persons high in this trait tend to be well-organised, goal-directed and persistent), neuroticism (persons high in this trait tend to experience strong levels of distress) and openness (people high in openness have broad interests and seek experiences).
Big-Five personality traits can affect HRQoL of different disorders because they could influence patients’ willingness to take treatment options, predispose to neuropsychiatric symptoms and affect coping strategies . Overall, conscientiousness was connected to higher compliance to treatments and indications of doctors, better physical and mental HRQoL, whereas neuroticism was linked to lower HRQoL [20,21,22,23,24,25,26].
Schoormans et al.  also showed that this adverse personality effect was limited to older men, suggesting that age should also be considered when exploring the relationship between personality traits and HRQoL in patients with other chronic diseases.
A similar type of inverse association between neuroticism and perceived health, showing how CKD patients with higher traits of neuroticism prove to be more preoccupied with their health symptoms, complaining about them more and consequently perceived poorer HRQoL .
Another relevant contribution by Poppe et al.  showed that CKD patients with neurotic personality tend to be less accepting of the disease and to endorse more denial. In support of this, the authors explain that high levels of neuroticism are usually associated with specific attitudes (inflexibility, withdrawal, passivity, wishful thinking, negative emotion focus, and less adaptive coping).
Beside this, the authors also hypothesised that the mental HRQoL of CKD patients can be directly explained by the relationship between neuroticism and the perception of health, as this association has been proven by many studies: neuroticism being associated with a worse perception of mental HRQoL [11, 24]. The authors explain that this negative association can probably be explained by the negative tendency of neurotic patients to be hyper-vigilant regarding the negative stimuli they encounter and excessively inattentive to the positive ones.
In addition, Ibrahim et al.  showed a positive association between extraversion and mental HRQoL, which is aligned with findings of other studies not strictly related to CKD patients . The explanation given by the author is that extraverted people are more likely to be easily distracted away from their disabilities.
Moreover, conscientiousness, agreeableness and openness were not associated with HRQoL. However, since conscientiousness in other studies proved to be predictive of higher treatment adherence  and conscientiousness and agreeableness were associated with higher self-rated health .
Illness denial in CKD
The concept of denial as recurrent defence mechanism in human experience was firstly introduced by Sigmund Freud (as cited in Rossi Ferrario et al. ) and subsequently refined by Anna Freud (as cited in Gagani et al. ) as an unintentional process which comes into play to reduce the anxiety caused by a specific threatening problem by preserving a person from something that he/she is not yet ready to face. For many years since this theorisation, denial has been considered mostly as uniquely pathological, but during the last times it has been recognised as playing a protective role in psychological functioning .
While generally considered as a unidimensional construct, other scholars suggested the complexity and fluctuation of denial and its negative and positive effects on HRQoL in chronic illness [33,34,35].
Nevertheless, a circular relationship was demonstrated between depression and negative self-care behaviours in CKD patients [30, 36], i.e., patients with depression are less likely to comply with medication, dialysis, and renal diet and more likely to have a sedentary lifestyle.
Recently, Rossi Ferrario et al.  proposed a new multidimensional model of denial and discussed its positive side as an effective strategy for facing the initial phases of an illness (i.e., invasive examinations or burdensome therapies), and the negative side when in its more severe, persistent forms, denial may lead to maladaptive behaviours and distress during the chronic course of the disease. The authors defined it as composed of two correlated components, namely denial of negative emotions (the emotional reactivity related to the individual’s emotional life and its regulation) and resistance to change (the behavioural efforts and life-style changes necessary to manage illness). The components represent a preliminary phase characterised by the removal of unpleasant material from consciousness. The authors also introduced a third independent component, the conscious avoidance, representing a later phase where awareness is present, but the individual voluntarily avoids facing the threatening situation.
In sum, following Gagani et al. , it is legitimate to assume that denial may be to some extent a functional strategy in the first phase of an illness, but it can prevent cure and control of chronic illness like CKD, particularly in the long run. Therefore, health professionals should verify whether CKD patients’ denial is adaptive or maladaptive so it can be addressed properly during treatment.
Rationale and hypotheses of the present study
Low attention has been dedicated to the personality profiles and illness denial in CKD patients and their relation with the domains of HRQoL. Poorer HRQoL can predict a higher risk of hospitalization and mortality, and broadly a worse adjustment to the dialytic therapy. Thus, a clearer knowledge of the psychological variables associated with a worse HRQoL in the predialysis stage might suggest specific interventions in this population, with the aim of improving their adjustment to the new therapeutic pathway [11, 16].
The aim of the present study was to investigate the association between illness denial and Big-Five personality traits and HRQoL dimensions beyond the effect of gender, age, medical comorbidity (cardiovascular respiratory diseases and dysmetabolism) and psychological distress (i.e., trait anxiety) in a group of patients with CKD in the predialysis stage. We hypothesised that conscientiousness, agreeableness and openness are related to better physical, mental and social dimensions of HRQoL, and that neuroticism is related to a worse HRQoL in all its dimensions.
Eligibility criteria and procedure
Participants were included if they met the criteria for a diagnosis of CKD, and they were in the pre-dialysis stage. Diagnosis of CKD was defined by indicators of kidney damage—imaging or proteinuria (i.e., albumin to creatinine ratio)—and decreased renal function (below thresholds of glomerular filtration rate estimated from serum creatinine concentration) for at least three months .
Participants were excluded if (a) medical diseases interfered with the completion of questionnaires (e.g., neurological diseases, psychiatric diseases, intellectual disabilities); (b) they were under 18 years of age; (c) they did not understand Italian at a sufficient level to complete the questionnaire. There were considered the parameters of creatinine, urinary creatinine, creatinine clearance and albumin in addition to age and gender, without the exclusion of any medical condition, because they were frequently associated with CKD . When patients were recruited, at that time the outpatient clinic had patients with a GFR between 100 and 20. In addition, uricemia as an expression of associated urate dysmetabolism and levels of sodium were assessed to document possible electrolyte imbalances.
One hundred participants were recruited in an outpatient ward at the Santa Maria alle Scotte University Hospital of Siena, in Italy. Data was collected from March to September 2019. All the participants completed the questionnaires individually with the assistance of a psychologist, who provided information about the aims of the study. In accordance with the Ethical Principles of Psychologists and Code of Conduct, all the participants, who were included, provided written informed consent to participate in the study after having received a detailed description of the aims.
Kidney Disease Quality of Life short form version 1.3 (KDQOL-SF) 
The KDQOL-SF 1 is a self-report questionnaire which consists of 11-item scales focusing on HRQoL issues specific to patients with CKD. These kidney disease-specific domains include List of Symptoms/Problems, Effects of Kidney Disease, Burden of Kidney Disease, Work Status, Cognitive Function, Quality of Social Interaction, Sexual Function, Sleep, Social Support. We linearly converted kidney disease-specific domain scores to a 0–100 scale in a similar manner to that used for the SF-36 domain scores. Higher scores suggest a higher perceived HR-QoL. A Kidney Disease Component Summary Score is generated as an average of these kidney disease-specific scales as previously reported . In present study, the internal consistency of all the scales was good (range of Cronbach’s alpha = 0.82–0.86).
Italian version of Ten Item Personality Inventory Revised (I-TIPI-R) 
The I-TIPI-R is a 10-item scale, each consisting of a pair of descriptors that were scored from 1 (strongly disagrees) to 7 (strongly agree). Two items represented each dimension of the Big Five (Extraversion, Agreeableness, Conscientiousness, Neuroticism, Openness), one stated in a way that constitutes the positive pole of the dimension, and the other reported in a way that serves the negative pole. The measure showed acceptable psychometric properties in terms of test–retest reliability, factor structure, convergent validity with other personality questionnaires . In the current study, the internal consistency of all the scales was acceptable to good (range of Cronbach’s alpha = 0.76–0.82).
Illness Denial Questionnaire (IDQ) 
It consists of 24 dichotomous items (false = 0; true = 1) evaluating three dimensions: Denial of Negative Emotions (7 items; example item, “I am worried about this disorder/disease”); Resistance to Change (9 items; example item, “The treatments (medications, exercises, or others) do not, in fact, change my life”), and Conscious Avoidance (8 items; example item, “I try to avoid thinking about this disorder/disease as much as I can”). The first two dimensions express the core of denial, while the latter represents a more advanced stage of the illness elaboration process. Higher scores express higher denial levels. In present study, the internal consistency of all the scales was good (range of Cronbach’s alpha = 0.80–0.85).
State-Trait Anxiety Inventory-Y form (STAI-Y) 
The STAI-Y is a 20-item self-report tool. Each item is rated on a 4-point Likert scale with higher scores denoting higher levels of trait anxiety. Internal consistency of the STAI-Y was very good for the total community sample (Cronbach’s alpha = 0.89), and excellent for the total clinical sample (alpha = 0.90) In current study, the internal consistency of the scale was excellent (Cronbach’s alpha = 0.90).
Pearson’s bivariate correlations were calculated between the KDQOL-SF scale scores and the STAI-Y Trait subscale, IDQ and I-TIPI-R scores. Values on the correlation coefficients were interpreted according to the following criteria : 0 < r <|.30|= weak; |.30|< r <|.50|= moderate; |.50|< r <|.70|= strong; |.70|< r <|1|= very strong. Power calculations were run for this analysis: for a medium effect size, 80% power, and significance set at the level described above, the required sample size for bivariate correlations was at least 64 participants.
Subsequently, to test the specific contribution of anxious symptoms, illness denial processes and personality traits, generalised linear models were conducted entering age, gender (male vs. female), and the scores on the STAI-Y Trait subscale, IDQ and I-TIPI-R as predictors and the scores on each of the KDQOL-SF scales as dependent variables. The variables followed a normal distribution, therefore an identity link function was used. Power calculations were run for this analysis: for a medium effect size, 70% power, and significance set at the level described above, the required sample size for bivariate correlations was 100 participants. The statistical analysis was conducted using the SPSS software version 25.00 software.
One hundred individuals with a diagnosis of CKD participated. Mean age was 75.87 years old (SD = 10.14, range = 42–94) and forty-one (41%) of the sample were females. The degree of CKD severity was assessed by collecting creatinine, creatinine clearance, and urea values. Descriptive socio-demographics, blood markers and scores on the questionnaires were reported in Table 1.
Associations between quality of life, illness denial and personality traits
The results of the correlational analyses are presented in Table 2. Scores on the IDQ Denial of Negative Emotions correlated moderately and positively with scores on the KDQOL-SF Effects of Kidney Disease, KDQOL-SF Burden of Kidney Disease, and KDQOL-SF Cognitive Function, and weakly with scores on the KDQOL-SF List of Symptoms/Problems and KDQOL-SF Sleep.
Positive and moderate associations emerged between scores on the IDQ Resistance to Change and scores on the KDQOL-SF Effects of Kidney Disease, KDQOL-SF Burden of Kidney Disease and KDQOL-SF Cognitive Function. Scores on the IDQ Conscious Avoidance were negatively and weakly related to scores on the KDQOL-SF Cognitive Function and KDQOL-SF Social Support. Scores on the KDQOL-SF Cognitive Function were associated positively and weakly with scores on I-TIPI-R Extraversion; scores on the KDQOL-SF Quality of Social Interaction correlated positively and weakly with scores on I-TIPI-R Agreeableness. Scores on the KDQOL-SF Work Status correlated positively and weakly with scores on I-TIPI-R Conscientiousness. Negative and weak correlations were found between scores on the KDQOL-SF Sleep and scores on I-TIPI-R Neuroticism. Scores on KDQOL-SF List of Symptoms/Problems correlated positively and weakly with scores on I-TIPI-R Openness.
Illness denial and personality traits as predictors of HRQoL
The results of the generalised linear models are presented in Table 3 and illustrated in Fig. 1. Scores on the STAI-Y Trait and I-TIPI-R Openness negatively (B = − 0.653; p = 0.000) and positively (B = 1.597; p = 0.009) predicted scores on the KDQOL-SF List of Symptoms/Problems respectively. Scores on the IDQ Denial of Negative Emotions positively predicted scores on the KDQOL-SF Effects of Kidney Disease (B = 1.536; p = 0.031). Age and scores on the IDQ Denial of Negative Emotions negatively (B = − 0.928; p = 0.001) and positively (B = 6.017; p = 0.000) predicted scores KDQOL-SF Burden of Kidney Disease respectively. Age and scores on the I-TIPI-R Extraversion negatively (B = − 1.113; p = 0.000) and positively (B = 1.591; p = 0.016) predicted scores on KDQOL-SF Work Status. The presence of dysmetabolism was associated with higher scores on the KDQOL-SF Work Status. Scores on the KDQOL-SF Cognitive Function were positively predicted by scores on the IDQ Denial of Negative Emotions (B = 3.766; p = 0.000), I-TIPI-R Agreeableness (B = 1.609; p = 0.009), I-TIPI-R Neuroticism (B = 1.884; p = 0.007) and negatively predicted by age and STAI-Y Trait (B = -0.708; p = 0.000). Female gender (B = 9.520; p = 0.008) and scores on the I-TIPI-R Agreeableness (B = 1.425; p = 0.036) positively predicted scores on the KDQOL-SF Quality of Social Interaction while scores on the STAI-Y Trait were negative predictors of this KDQOL-SF scale (B = − 0.523; p = 0.006). Scores on the KDQOL-SF Sexual Function were positively predicted by female gender (B = 14.468; p = 0.000) and scores on the IDQ Resistance to Change (B = 4.865; p = 0.000), I-TIPI-R Extraversion (B = 1.729; p = 0.000), I-TIPI-R Agreeableness (B = 1.286; p = 0.000), I-TIPI-R Conscientiousness (B = 0.950; p = 0.000), and I-TIPI-R Neuroticism (B = 0.759; p = 0.000), and negatively by age (B = − 0.553; p = 0.000). Scores on the KDQOL-SF Social Support were negatively predicted by scores on the IDQ Conscious Avoidance (B = -2.980; p = 0.011). Scores on the KDQOL-SF Kidney Disease Component Summary Score were predicted negatively by scores on the STAI-Y Trait (B = − 0.649; p = 0.001) and cardiovascular respiratory diseases (B = − 9.801; p = 0.013).
The present work is the first investigation which simultaneously assessed Big-Five personality traits and illness denial in the different domains of HRQoL of CKD patients in the predialysis stage. The results showed that different illness denial dimensions and Big-Five personality traits have a specific role in specific HRQoL dimensions of CKD.
Illness denial was associated with increased HRQoL in symptoms, effect, burden of kidney disease and cognitive functions domains, and it was a predictor of higher HRQoL in the last three domains mentioned above. Extraversion was related to better work status and sexual function; agreeableness was linked to elevated cognitive function, quality of social interaction and sexual function; conscientiousness was related to better sexual function; neuroticism was linked to improved cognitive and sexual functions; in the end, openness to experience was related to fewer symptoms and problems.
The role of illness denial in HRQoL of CKD patients
Denial of negative emotions and resistance to change were found to be associated with the same dimensions of HRQoL. Individuals with high denial of negative emotions and resistance to change tended to report higher quality of life related to symptom/problems, the effect of kidney disease, the burden of kidney disease and cognitive function. Such findings seem to be the evidence that these dimensions of denial might represent an actual expression of denial, whereas conscious avoidance seems to constitute a different step in the process of cognitive-affective processing of the illness . In addition, higher denial of negative emotions was related to a more elevated HRQoL linked to the disease effect, burden and cognitive function.
Therefore, individuals who reported elevated levels of denial tended to claim that they were not bothered by the effects of the kidney disease on daily life (e.g., restriction on fluid, dietary intake, impact on work etc.), did not perceive high levels of frustration and interference of kidney disease in their life, and did not report any concentration problems or mental confusion. It may be the one’s tendency to deny negative emotions, which arises from the effect and burden of CKD, making people report that they experience a better HRQoL in the above-mentioned areas. Being aware of one’s own distancing from the illness may represent not only the point in the denial process at which acceptance of the illness’s existence begins , but also it may be an effective method for facing the phases of the illness and improving the perceived HRQoL. It can be also speculated that the tendency to illness denial, making subjects feel not to be sick, protected them from a worsening of their HRQoL.
The finding that people with higher conscious avoidance had lower levels of social support suggests that individuals with a greater tendency to avoid and take distance from the real condition were less satisfied with their social support. People who asserted, for example, that “less I know, the better I feel” or “I try not to speak about this disorder/disease” might feel like they did not need the support of their friends or family; social support could be actually a way to make the illness more real and close. Nevertheless, individuals who do not perceive adequate social support could tend to voluntarily avoid facing the threatening situation, having already awareness of the illness. That could imply that social support would be a resource for the individual who is trying to cope with kidney disease.
The role of Big-Five personality traits in HRQoL of CKD patients
Assessing the correlation between personality traits and HRQoL means comparing a construct that is relatively stable (the first) with a construct that can change over time; which means that the relationship between those construct may change.
Extraversion was associated with positive cognitive function, in line with the evidence which highlighted a relation between extraversion and better mental health in patients with CKD  and with findings, in kidney transplant recipients, indicating that extroverted people are more likely to be distracted away from disabilities by focusing on external stimulation and by engaging in daily activities . Quality of social interaction was related to agreeableness, suggesting that amiable patients with CKD have better social support, in line with previous research [11, 29]. People with higher conscientiousness tended to report to be more capable of working. This could be explained as conscientiousness, being related to greater adherence to treatment , could be indirectly linked with a better HRQoL and thus, indirectly, a better work performance and status. The trait of openness to experience was related to and was a predictor of a greater HRQoL concerning symptoms/problems, in contrast with the literature on general population where openness seems to be unrelated to self-rated health . This could mean that individuals who are more “open to experience” might be less in touch with their inner body signals and thus be less negatively focused on their symptoms . Traits of agreeableness and neuroticism both predicted a better cognitive function. Consistently with a previous study , agreeableness predicted a better self-rated health, but only one study found a relation between agreeableness and quality of life in patients with chronic renal failure . In contrast with several studies in general population , in kidney transplant recipients  and in CKD patients [29, 44], in our investigation neuroticism was found to be a predictor of a better quality of life in the cognitive function domain. Individuals with higher neuroticism were likely to be more concerned about the illness and hyper-vigilant towards negative stimuli that they encountered. Patients with neurotic traits may report better cognitive functioning to be believed in their complaints about their symptoms, in line with Ferentzi et al. . Patients with higher denial of the disease could claim to have a good cognitive function. We could also speculate that individuals with high neuroticism would tend to seek a lot of information. This could result in higher levels of health literacy, which together with low levels of cognitive impairment were associated with increased quality of life [17, 45]. Lastly, extraversion, agreeableness, conscientiousness and neuroticism were predictors of a greater sexual function.
Role of socio-demographic and clinical variables
This study reports important effects of some socio-demographic predictors on the HRQoL of individuals with CKD. First, older age was found to be a predictor of a worse HRQoL related to the burden of kidney disease, work status, cognitive and sexual functions. The interpretation of this finding, which is consistent with previous studies [11, 46], should take into account that older age implies a longer duration of illness and contextually there may be an amount of other factors that could influence the quality of life of the patients. Feminine gender was a predictive factor of a better HRQoL in the domains of sexual function and quality of social interaction. Therefore, being a woman seems to be associated with a lower impact of kidney disease on individual’s sexual functioning and social isolation. The comorbidity with cardiovascular respiratory disease, which is frequent in patients with CKD , was a predictor of worse general HRQoL. In fact, comorbidity reduces chances of survival and increases hospitalisation . Dysmetabolism was a predictor of a better HRQoL, mostly impacting the work status and sexual function. Lastly, trait anxiety was negatively associated with and was a negative predictor of nearly all the dimensions of the HRQoL, indicating that this stable trait of personality, characterised by high reactivity to stimulation and high arousal , predicted lower perception of HRQoL.
Limitations and future directions
The cross-sectional study design did not allow us to reliably ascertain the role of illness denial and Big Five traits as risk factors for a worse HRQoL. Furthermore, in our case, multiple testing could imply a large probability that some of the true null hypotheses will be rejected, thus resulting in type I error. In addition, a multicentre design could increase the generalisability of the findings to different healthcare settings. Another limitation concerned the use of self-report questionnaires, which should be combined with future interviews made by clinicians.
Although the association between illness denial and HRQoL we has been shown in the present work, the results could be interpreted that denial attitude affected only responses to the questionnaire, rather than affecting HRQoL itself. Nevertheless, since HRQoL is a much broader construct, it should be investigated by further, more objective measures. Thereby, the association would also be strengthened. Furthermore, since personality traits are a relatively stable construct over time [18, 48], whereas the HRQoL may change, forthcoming studies should use a longitudinal design to explore this dynamic relationship over time.
Duration of illness was not evaluated, and additional markers were not considered due to lack of laboratory data at the time of questionnaire administration. In addition, future research should take into account further covariates related to blood markers such as proteinuria, anaemia, hemoglobin levels, siderosis, and potassium levels that can be associated with illness severity. However, we did not have enough statistical power due to the relatively small sample size.
Furthermore, it could be helpful to consider the relationships between the above evidence and the state of depression in CKD patients. In fact, from past studies, depression was found to be common amongst the patients with chronic physical health problems [49, 50], and in those affected by CKD depression levels seem to be even higher than that reported levels for the patients with other chronic diseases . Another variable that might be involved as a moderator of the relations between illness denial/personality traits and HRQoL could be the stage of the disease, i.e., being or not on haemodialytic therapy. Additional variables may also include further social and demographic features that can negatively impact on health literacy and access to healthcare services such as immigrant status which has been found to be a predictor of several chronic diseases [52,53,54].
It would be interesting, in the future, to investigate the possible correlation between the personality trait openness and a greater perception of one's disease or, vice versa, a judgemental attitude towards one’s disease. Further studies based on a larger sample size would be warranted to expand the knowledge on this subject, in the belief that better acquisitions can lead to specific and personalised interventions both from a physical and mental point of view, as found for other chronic diseases [55, 56]. Finally, future research should explore more in depth the inter-relationships between the predictors by testing interaction effects through moderation analysis in larger samples. In addition, further studies based on larger samples should identify subgroups of patients on specific clinical and psychological features by latent profile analysis.
To our knowledge, this is the first study which simultaneously assessed Big-Five personality traits and illness denial in different domains of HRQoL of CKD patients. Illness denial was associated with increased HRQoL related to symptoms/problems, effect and burden of kidney disease and cognitive functions domains, and it was a predictor of higher HRQoL in the last three domains mentioned above. Extraversion was related to better work status and sexual function; agreeableness was linked to elevated cognitive function, quality of social interaction and sexual function; conscientiousness was related to better sexual function; neuroticism was linked to improved cognitive and sexual functions; in the end, openness to experience was related to fewer symptoms and problems.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Kidney Chronic Disease
Health-Related Quality of Life
Kidney Disease Quality of Life Short form
Ten Item Personality Inventory Revised
Illness Denial Questionnaire
State-Trait Anxiety Inventory Form-Y
Sprangers MA. Quality-of-life assessment in oncology. Achiev Chall Acta Oncol. 2002;41(3):229–37. https://doi.org/10.1080/02841860260088764.
Devins GM, Binik YM, Hutchinson TA, Hollomby DJ, Barré PE, Guttmann RD. The emotional impact of end-stage renal disease: importance of patients’ perception of intrusiveness and control. Int J Psychiatry Med. 1984;13(4):327–43. https://doi.org/10.2190/5dcp-25bv-u1g9-9g7c.
Coluccia A, Fagiolini A, Ferretti F, Pozza A, Goracci A. Obsessive-compulsive disorder and quality of life outcomes: protocol for a systematic review and meta-analysis of cross-sectional case-control studies. Epidemiol Biostat Public Health. 2015. https://doi.org/10.2427/10037.
Pugi D, Dèttore D, Marazziti D, Ferretti F, Coluccia A, Coccia ME, Pozza A. Fertility-related quality of life in men undergoing medically assisted reproduction during the pandemic: perfectionism and thought control beliefs moderate the effects of the type of treatment. Clin Neuropsychiatry. 2021;18(6):312–23. https://doi.org/10.36131/cnfioritieditore20210605.
Pozza A, Veale D, Marazziti D, Delgadillo J, Albert U, Grassi G, Prestia D, Dèttore D. Sexual dysfunction and satisfaction in obsessive compulsive disorder: protocol for a systematic review and meta-analysis. Syst Rev. 2020;9(1):1–13. https://doi.org/10.1186/s13643-019-1262-7.
Pozza A, Dèttore D, Coccia ME. Depression and anxiety in pathways of medically assisted reproduction: the role of infertility stress dimensions. Clin Pract Epidemiol Ment Health. 2019;15:101–9. https://doi.org/10.2174/1745017901915010101.
Megari K. Quality of Life in Chronic Disease Patients. Health Psychol Res. 2013;1(3):e27. https://doi.org/10.4081/hpr.2013.e27.
Stevens PE, Levin A, Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013;158(11):825–30. https://doi.org/10.7326/0003-4819-158-11-201306040-00007.
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S1–266.
NICE. Chronic kidney disease: assessment and management NICE guideline [Internet]. 2021 [cited 2022 May 16]. 72 p. Cat. No.: NG203. Available from: https://www.nice.org.uk/guidance/ng203
Ibrahim N, Teo SS, Che Din N, Abdul Gafor AH, Ismail R. The role of personality and social support in Health-Related Quality of life in chronic kidney disease patients. PLoS ONE. 2015;10(7):e0129015. https://doi.org/10.1371/journal.pone.0129015.
Hill NR, Fatoba ST, Oke JL, Hirst JA, O’Callaghan CA, Lasserson DS, Hobbs FD. Global prevalence of chronic kidney disease—a systematic review and meta-analysis. PLoS ONE. 2016;11(7):e0158765. https://doi.org/10.1371/journal.pone.0158765.
Chin HJ, Song YR, Lee JJ, Lee SB, Kim KW, Na KY, Kim S, Chae DW. Moderately decreased renal function negatively affects the health-related quality of life among the elderly Korean population: a population-based study. Nephrol Dial Transplant. 2008;23(9):2810–7. https://doi.org/10.1093/ndt/gfn132.
Kalfoss M, Schick-Makaroff K, Molzahn AE. Living with chronic kidney disease: illness perceptions, symptoms, coping, and quality of life. Nephrol Nurs J. 2019;46(3):277–90.
Perlman RL, Finkelstein FO, Liu L, Roys E, Kiser M, Eisele G, Burrows-Hudson S, Messana JM, Levin N, Rajagopalan S, Port FK, Wolfe RA, Saran R. Quality of life in chronic kidney disease (CKD): a cross-sectional analysis in the Renal Research Institute-CKD study. Am J Kidney Dis. 2005;45(4):658–66. https://doi.org/10.1053/j.ajkd.2004.12.021.
Tsai YC, Hung CC, Hwang SJ, Wang SL, Hsiao SM, Lin MY, Kung LF, Hsiao PN, Chen HC. Quality of life predicts risks of end-stage renal disease and mortality in patients with chronic kidney disease. Nephrol Dial Transplant. 2010;25(5):1621–6. https://doi.org/10.1093/ndt/gfp671.
Webster AC, Nagler EV, Morton RL, Masson P. Chronic kidney disease. Lancet. 2017;389(10075):1238–52. https://doi.org/10.1016/S0140-6736(16)32064-5.
McCrae RR, Costa PT Jr. Personality in adulthood: a five-factor theory perspective. 2nd ed. New York: Guilford; 2005.
Graham EK, Weston SJ, Gerstorf D, Yoneda TB, Booth T, Beam CR, et al. Trajectories of Big Five personality traits: a coordinated analysis of 16 longitudinal samples. Eur J Pers. 2020;34(3):301–21. https://doi.org/10.1002/per.2259.
Bogg T, Roberts BW. Conscientiousness and health-related behaviors: a meta-analysis of the leading behavioral contributors to mortality. Psychol Bull. 2004;130(6):887–919. https://doi.org/10.1037/0033-2909.130.6.887.
Chapman B, Duberstein P, Lyness JM. Personality traits, education, and health-related quality of life among older adult primary care patients. J Gerontol B Psychol Sci Soc Sci. 2007;62(6):P343–52. https://doi.org/10.1093/geronb/62.6.p343.
Goodwin R, Engstrom G. Personality and the perception of health in the general population. Psychol Med. 2002;32(2):325–32. https://doi.org/10.1017/s0033291701005104.
Goodwin RD, Friedman HS. Health status and the five-factor personality traits in a nationally representative sample. J Health Psychol. 2006;11(5):643–54. https://doi.org/10.1177/1359105306066610.
Hudek-Knezević J, Kardum I. Five-factor personality dimensions and 3 health-related personality constructs as predictors of health. Croat Med J. 2009;50(4):394–402. https://doi.org/10.3325/cmj.2009.50.394.
Rochefort C, Hoerger M, Turiano NA, Duberstein P. Big Five personality and health in adults with and without cancer. J Health Psychol. 2019;24(11):1494–504. https://doi.org/10.1177/1359105317753714.
Turiano NA, Pitzer L, Armour C, Karlamangla A, Ryff CD, Mroczek DK. Personality trait level and change as predictors of health outcomes: findings from a national study of Americans (MIDUS). J Gerontol B Psychol Sci Soc Sci. 2012;67(1):4–12. https://doi.org/10.1093/geronb/gbr072.
Schoormans D, Husson O, Denollet J, Mols F. Is Type D personality a risk factor for all-cause mortality? A prospective population-based study among 2625 colorectal cancer survivors from the PROFILES registry. J Psychosom Res. 2017;96:76–83. https://doi.org/10.1016/j.jpsychores.2017.03.004.
Prihodova L, Nagyova I, Rosenberger J, Roland R, van Dijk JP, Groothoff JW. Impact of personality and psychological distress on health-related quality of life in kidney transplant recipients. Transpl Int. 2010;23(5):484–92. https://doi.org/10.1111/j.1432-2277.2009.01003.x.
Poppe C, Crombez G, Hanoulle I, Vogelaers D, Petrovic M. Improving quality of life in patients with chronic kidney disease: influence of acceptance and personality. Nephrol Dial Transplant. 2013;28(1):116–21. https://doi.org/10.1093/ndt/gfs151.
Rossi Ferrario S, Giorgi I, Baiardi P, Giuntoli L, Balestroni G, Cerutti P, Manera M, Gabanelli P, Solara V, Fornara R, Luisetti M, Omarini P, Omarini G, Vidotto G. Illness denial questionnaire for patients and caregivers. Neuropsychiatr Dis Treat. 2017;13:909–16. https://doi.org/10.2147/NDT.S128622.
Gagani A, Gemao J, Relojo D, Pilao SJ. The stages of denial and acceptance among patients with chronic kidney disease. J Innov Psychol Educ Didact. 2016;20(2):113–24.
Cramer P. Defense mechanisms in psychology today. Further processes for adaptation. Am Psychol. 2000;55(6):637–46. https://doi.org/10.1037//0003-066x.55.6.637.
Havik OE, Maeland JG. Dimensions of verbal denial in myocardial infarction. Correlates to 3 denial scales. Scand J Psychol. 1986;27(4):326–39. https://doi.org/10.1111/j.1467-9450.1986.tb01211.x.
Jacobsen BS, Lowery BJ. Further analysis of the psychometric properties of the Levine Denial of Illness Scale. Psychosom Med. 1992;54(3):372–81. https://doi.org/10.1097/00006842-199205000-00012.
Levine J, Warrenburg S, Kerns R, Schwartz G, Delaney R, Fontana A, Gradman A, Smith S, Allen S, Cascione R. The role of denial in recovery from coronary heart disease. Psychosom Med. 1987;49(2):109–17. https://doi.org/10.1097/00006842-198703000-00001.
Bautovich A, Katz I, Smith M, Loo CK, Harvey SB. Depression and chronic kidney disease: a review for clinicians. Aust NZ J Psychiatry. 2014;48(6):530–41. https://doi.org/10.1177/0004867414528589.
Korevaar JC, Merkus MP, Jansen MA, Dekker FW, Boeschoten EW, Krediet RT, NECOSAD-Study Group. Validation of the KDQOL-SF: a dialysis-targeted health measure. Qual Life Res. 2002;11(5):437–47. https://doi.org/10.1023/a:1015631411960.
Saban KL, Stroupe KT, Bryant FB, Reda DJ, Browning MM, Hynes DM. Comparison of health-related quality of life measures for chronic renal failure: quality of well-being scale, short-form-6D, and the kidney disease quality of life instrument. Qual Life Res. 2008;17(8):1103–15. https://doi.org/10.1007/s11136-008-9387-5.
Chiorri C, Bracco F, Piccinno T, Modafferi C, Battini V. Psychometric properties of a revised version of the ten item personality inventory. Eur J Psychol Assess. 2010. https://doi.org/10.1027/1015-5759/a000215.
Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the state-trait anxiety inventory. Palo Alto: Consulting Psychologists Press; 1983.
Cohen J. Statistical power analysis for the behavioral sciences. London: Routledge; 1988.
Ferentzi E, Köteles F, Csala B, Drew R, Tihanyi BT, Pulay-Kottlár G, Doering BK. What makes sense in our body? Personality and sensory correlates of body awareness and somatosensory amplification. Personal Individ Differ. 2017;104:75–81. https://doi.org/10.1016/j.paid.2016.07.034.
Bakhtiari M, Falaknazi K, Lotfi M, Noori M. The relationship between personality traits, anxiety and depression, in life quality of patients under treatment by Hemodialysis. Nov Biomed. 2013;1(1):1–7. https://doi.org/10.22037/nbm.v1i1.4575.
Widjast EP, Halim MS. Personality, coping strategy, and quality of life of patients with chronic kidney disease. J Psikol. 2021;48(3):199–213. https://doi.org/10.22146/jpsi.37875.
Pozza A, Osborne RH, Elsworth GR, Ferretti F, Coluccia A. Italian validation of the health education impact questionnaire (heiQ) in people with chronic conditions. Health Qual Life Outcomes. 2020;18(1):89. https://doi.org/10.1186/s12955-020-01329-9.
Mujais SK, Story K, Brouillette J, Takano T, Soroka S, Franek C, Mendelssohn D, Finkelstein FO. Health-related quality of life in CKD patients: correlates and evolution over time. Clin J Am Soc Nephrol. 2009;4(8):1293–301. https://doi.org/10.2215/CJN.05541008.
Cattell RB, Scheier IH. Stimuli related to stress, neuroticism, excitation, and anxiety response patterns: illustrating a new multivariate experimental design. J Abnorm Soc Psychol. 1960;60:195–204. https://doi.org/10.1037/h0046347.
McCrae RR, Costa PT Jr. Self-concept and the stability of personality: cross-sectional comparisons of self-reports and ratings. J Personal Soc Psychol. 1982;43:1282–92.
Harvey SB, Ismail A. Psychiatric aspects of chronic physical disease. Medicine. 2008;36(9):471–4. https://doi.org/10.1016/j.mpmed.2008.07.003.
Olver JS, Hopwood MJ. Depression and physical illness. Med J Aust. 2013;199(S6):S9-12. https://doi.org/10.5694/mja12.10597.
Palmer SC, Vecchio M, Craig JC, Tonelli M, Johnson DW, Nicolucci A, Pellegrini F, Saglimbene V, Logroscino G, Hedayati SS, Strippoli GF. Association between depression and death in people with CKD: a meta-analysis of cohort studies. Am J Kidney Dis. 2013;62(3):493–505. https://doi.org/10.1053/j.ajkd.2013.02.369.
Nisar M, Uddin R, Kolbe-Alexander T, Khan A. The prevalence of chronic diseases in international immigrants: a systematic review and meta-analysis. Scand J Public Health. 2022. https://doi.org/10.1177/14034948221116219.
Coluccia A, Ferretti F, Fagiolini A, Pozza A. Incidenza e fattori di rischio per disturbi psicotici nelle popolazioni migranti in Europa: una meta-analisi di studi trasversali. Rass Ital Criminol. 2015;9(1):29–39.
Diolaiuti F, Marazziti D, Beatino MF, Mucci F, Pozza A. Impact and consequences of COVID-19 pandemic on complicated grief and persistent complex bereavement disorder. Psychiatry Res. 2021;300:113916. https://doi.org/10.1016/j.psychres.2021.113916.
Conversano C, Orrù G, Pozza A, Miccoli M, Ciacchini R, Marchi L, Gemignani A. Is mindfulness-based stress reduction effective for people with hypertension? A systematic review and meta-analysis of 30 years of evidence. Int J Environ Res Public Health. 2021;18(6):2882. https://doi.org/10.3390/ijerph18062882.
Wang T, Tan JY, Xiao LD, Deng R. Effectiveness of disease-specific self-management education on health outcomes in patients with chronic obstructive pulmonary disease: an updated systematic review and meta-analysis. Patient Educ Couns. 2017;100(8):1432–46. https://doi.org/10.1016/j.pec.2017.02.026.
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Pugi, D., Ferretti, F., Galeazzi, M. et al. Health-Related Quality of Life in pre-dialysis patients with chronic kidney disease: the role of Big-Five personality traits and illness denial. BMC Psychol 10, 297 (2022). https://doi.org/10.1186/s40359-022-00992-5