Author info: Correspondence should be sent to: Dr. Kymberley K.

Bennett,
Department of Psychology, Cherry Hall, Room 302, University of Missouri
Kansas City, Kansas City, MO, 64110. Email: bennettkk@umkc.edu.
North American Journal of Psychology, 2012, Vol. 14, No. 2, 293-306.
NAJP
Pessimistic Attributional Style and Cardiac
Symptom Experiences:
Self-Efficacy as a Mediator

Kymberley K. Bennett, Alisha D. Adams, & Jillian M. Ricks
University of Missouri Kansas City

This study tested the hypothesis that self-efficacy mediates the
relationship between pessimistic attributional style and experiences of
cardiac symptoms among a sample of cardiac rehabilitation (CR)
patients. Questionnaire data were collected from 100 patients at the
beginning of CR (Time 1), at the end of CR, 12 weeks later (Time 2), and
six months after CR completion (Time 3). Results of path models showed
that Time 1 generality scores (the sum of stability and globality ratings)
were negatively associated with Time 2 diet self-efficacy, but were un-
related to Time 2 exercise self-efficacy. In turn, both forms of self-
efficacy were negatively associated with Time 3 cardiac symptom
experiences. Findings suggest that self-efficacy should be studied as a
mediator of the relationship between pessimistic attributional style and
poor health, and they echo other research demonstrating the importance
of self-efficacy in CR patients recovery. Theoretically, our results
support a focus on the effects of generality scores (the sum of stable and
global dimensions) on health, rather than the internal dimension.
Clinically, our results suggest that CR providers should screen for
tendencies to see the causes of negative events as long-lasting and
pervasive, and assess patients for self-efficacy in domains relevant to CR.

Cardiovascular disease (CVD) is the leading cause of death in the
United States (Roger et al., 2011). It is estimated that one American dies
from CVD every 39 seconds, and that 33.6% of deaths in 2007 were
attributable to CVD. Currently, the American Heart Association
estimates that one in three Americans has at least one form of CVD.
These prevalence data underscore the importance of secondary
prevention programs, like cardiac rehabilitation (CR), for CVD patients.
CR programs have been shown to markedly affect health outcomes,
including reducing rates of all-cause mortality, cardiac-related mortality,
and myocardial infarction, and improving functional status, quality of life
appraisals, and modifiable risk factors such as cholesterol levels and
blood pressure (Clark, Hartling, Vandermeer, & McAlister, 2005; Taylor
et al., 2004). Over the past two decades, pessimistic attributional style
has emerged as a psychosocial correlate of poor health, including CVD.
294 NORTH AMERICAN JOURNAL OF PSYCHOLOGY
Attributional style is defined as the way in which people explain the
causes of negative events involving themselves. It is comprised of three
dimensions from which attributions about the causes of negative events
are made: (a) internality, (b) stability, and (c) globality (Peterson,
Buchanan, & Seligman, 1995). Internality is the degree to which an event
is attributed to something about oneself, stability reflects the degree to
which an event is a result of long-lasting causes, and globality refers to
the pervasiveness of the cause of an event. People who characteristically
explain the causes of negative events as internal, stable, and global are
said to have a pessimistic attributional style; conversely, individuals who
attribute the causes of negative events to external, unstable, and specific
forces are said to exhibit an optimistic attributional style. Research has
shown that male participants in a CVD prevention program with a
pessimistic attributional style were more likely to die than their
optimistic counterparts (Buchanan, 1995), and that the stable dimension
had the strongest relationship with mortality of the three dimensions. In
another study, the stable dimension interacted with socioeconomic status
(SES) to affect blood pressure, a strong risk factor for CVD, among
women (Grewen et al., 2000). That is, women who scored high on
stability and were identified as being of low SES had significantly higher
systolic blood pressures than women who scored high on stability but
were of high SES, as well as women who scored low on stability,
regardless of SES.
Adopting a pessimistic attributional style has been linked to other
forms of poor health, including illness (Dykema, Bergbower, & Peterson,
1995), poor immune functioning (Kamen-Siegel, Rodin, Seligman, &
Dwyer, 1991), poor metabolic control (Kuttner, Delamater, & Santiago,
1990), morbidity (Levy, Slade, & Ranasinghe, 2009; Peterson, Seligman,
& Vaillant, 1988), and mortality (Peterson, Seligman, Yurko, Martin, &
Friedman, 1998). Research also has demonstrated independent, negative
effects of the stable and global dimensions on health status. For example,
the stable dimension has been linked to self-reported disability among
rheumatoid arthritis patients (Hommel et al., 2000) and poor self-reported
health among CVD patients in CR (Bennett & Elliott, 2005). Research
also has shown the global dimension to be a correlate of self-reported
illness experiences (Bennett & Elliott, 2002; Chaney et al., 1996) and
mortality (Peterson et al., 1998).
With the establishment of pessimistic attributional style as a correlate
of poor health, researchers have examined the possible mechanisms
underlying this relationship. Several mediators have been suggested
(Peterson, 1995). First, it is possible that people with a pessimistic
attributional style perceive or experience more stress in their lives,
which, in turn negatively affects health (Dykema et al., 1995). Second,
Bennett, Adams, & Ricks ATTRIBUTIONAL STYLE 295
people adopting a pessimistic attributional style may have difficulty
establishing friendships, and therefore lack the protective effects of social
support on health. Third, it has been suggested that people with a
pessimistic attributional style become behaviorally passive on account of
the perceived independence between their actions and outcomes.
Consequently, they may see no benefit in engaging in health-promoting
behaviors (Lin & Peterson, 1990). Fourth, symptoms of depression may
serve as a mechanism linking pessimistic attributional style to poor
health. Although research shows that pessimistic attributional style is a
risk factor for depression (Sweeney, Anderson, & Bailey, 1986), results
are mixed when testing depression as a mediator. Support for a mediating
role of depressive symptoms was reported for college students (Bennett
& Elliott, 2002; Buchanan, Gardenswartz, & Seligman, 1999), but not for
older adults (Kamen-Siegel et al., 1991) or adolescents with diabetes
(Kuttner et al., 1990).
Therefore, additional research is needed to examine the specific
mechanisms linking pessimistic attributional style to poor health,
especially among CVD patients. One psychosocial candidate for
mediation is self-efficacy, or a patients confidence in his/her ability to
perform a behavior, which, when performed, should result in a desirable
outcome (Bandura, 1977). When applied to the health domain, self-
efficacy refers to ones confidence to enact health behaviors which
should positively impact health status. For CR patients, research has
demonstrated self-efficacy to be related to gains in cardiopulmonary
fitness (Cheng & Boey, 2002) and psychosocial adjustment (Burns &
Evon, 2007), and to compliance with CR (Maddison & Prapavessis,
2004). In addition, low self-efficacy among heart disease patients was
associated with a greater likelihood of hospitalization for heart failure
and all-cause mortality across four years of follow-up. Results showed
these associations were explained by poor cardiovascular functioning
(e.g., left ventricular ejection fraction) at baseline for patients low in self-
efficacy (Sarkar, Ali, & Whooley, 2009), suggesting that assessments of
self-efficacy may be important when implementing plans for recovery for
CR patients.
No research of which we are aware has tested self-efficacy as a
mediator of the link between pessimistic attributional style and poor
health. It is possible that feelings of hopelessness and helplessness
experienced by people with a pessimistic attributional style may manifest
as feelings of low self-efficacy. The reformulated learned helplessness
model suggests that adopting a pessimistic attributional style results in a
perceived independence between ones actions and outcomes (Abramson,
Seligman, & Teasdale, 1978). If true, these feelings may translate to low
confidence levels to enact healthy behaviors. Within the CR domain,
296 NORTH AMERICAN JOURNAL OF PSYCHOLOGY
feeling that ones actions do not impact ones outcomes may negatively
affect self-efficacy to enact the changes prescribed by CR staff (e.g.,
establishment of an exercise routine). In turn, research has already
demonstrated the effects of low self-efficacy on CR-related endpoints
(e.g., Sarkar et al., 2009). Thus, the current study was undertaken to test
the hypothesis that self-efficacy serves as a mediator of the relationship
between pessimistic attributional style and poor health, here
operationalized as the experience of cardiac symptoms, among CR
patients.
METHOD
Participants
Data were collected from 100 patients (69.0% male) participating in
Phase II CR programs. These programs are comprised of monitored
exercise classes and lifestyle change classes focusing on stress
management, pharmacology, and proper diet. This sample represents
participants from a larger study who completed questionnaires at all three
times.
1
At Time 1, ages ranged from 38 to 85 years, with an average age
of 63.7 years (SD = 9.8). A vast majority of the sample reported their
ethnic background to be European American (94.0%), with 4.0% African
American, 1.0% Asian, 1.0% Native American, and one person failing to
provide his/her ethnic background. Although most participants were
married or living with a partner (77.0%), 10.0% were widowed, 9.0%
reported being divorced, 3.0% were single and had never married, and
1.0% was separated from his/her spouse. Most participants had
completed high school or attended a college or trade school (42.4%),
whereas 13.1% held a 2-year college degree, 22.2% held a 4-year college
degree, and 22.2% completed a graduate degree. A majority of
participants reported not working outside the home (64.0%) and the
average household income range for the previous year was between
$60,000 and $69,999.
Participants diagnoses varied widely. The most common diagnosis,
for which 23.0% were referred to CR, was the placement of a stent. The
other most common diagnoses were MI with the placement of a stent
(14.0%), CABG (5.0%), and MI alone (4.0%). Participants were
stratified by risk for disease progression on the basis of American
Association of Cardiovascular and Pulmonary Rehabilitation guidelines
(2004). Risk stratification assignments of low, moderate, or high were
made by CR staff and based on participants diagnoses, prior cardiac
events if appropriate, and current risk factors (e.g., smoking, concurrent
ailments, diet). Risk stratification assignments were used by CR staff to
customize participants target energy expenditures during exercise
sessions, but were not explicitly shared with participants. Within this
sample, 51.2% were stratified as low in risk for disease progression,
Bennett, Adams, & Ricks ATTRIBUTIONAL STYLE 297
whereas 45.0% and 3.8% were assigned moderate and high risk
stratifications, respectively. Finally, participants attended an average of
17.8 exercise sessions (SD = 7.4) during their 12-week cardiac
rehabilitation programs.

Measures
A self-administered questionnaire comprised of several standardized
measures previously used with cardiac populations was utilized in the
study. Questionnaires were completed at the beginning of CR (Time 1),
at the completion of CR (Time 2), and six months after completion of CR
(Time 3).
Pessimistic attributional style. At Time 1, pessimistic attributional
style was assessed with the Attributional Style Questionnaire-Revised
(ASQ-R; Dykema, Bergbower, Doctora, & Peterson, 1996). The ASQ-R
presents participants with six hypothetical, negative situations (e.g., you
have trouble sleeping, you cant get done all the tasks that others expect
of you). Participants are asked to write the main cause for each event,
followed by ratings of each cause on internal, stable, and global
dimensions. Ratings are made on 7-point scales (e.g., will never affect
you again to will always affect you). According to the reformulated
learned helplessness model (Abramson, Seligman, &Teasdale, 1978),
each dimension of pessimistic attributional style is hypothesized to result
in unique intrapersonal consequences: internality with loss of self-
esteem, stability with long-lasting feelings of hopelessness, and globality
with pervasive feelings of helplessness. More recently, researchers have
focused on the stable and global dimensions to create a generality score,
as internality has produced mixed results with outcomes (e.g., Bennett &
Elliott, 2005; Hommel, Wagner, Chaney, & Mullins, 2001). Moreover,
Janoff-Bulman (1992) distinguishes between different types of internal
attributions (i.e., behavioral ones that are controllable versus
characterological ones that are uncontrollable), and her theory has
received support (e.g., Friedman et al., 2007). Therefore, as done in
previous research, we computed a generality score that includes
responses to the stable and global questions (e.g., Fresco, Heimberg,
Abramowitz, & Bertram, 2006; Lo, Yo, & Hollon, 2010). Higher
generality scores reflect stronger beliefs that negative events are due to
long-lasting and pervasive causes.
Diet self-efficacy. Self-efficacy about dietary improvements at Time
2 was measured via the Cardiac Diet Self-Efficacy Inventory (CDSEI;
Hickey, Own, & Froman, 1992). The CDSEI is a 16-item scale designed
to assess cardiac patients confidence in making a variety of dietary
changes (e.g., staying on a healthy diet when busy or in a rush, knowing
how to cook healthy meals). Responses to items are made on a 5-point
298 NORTH AMERICAN JOURNAL OF PSYCHOLOGY
scale (very little confidence to quite a lot of confidence) and summed,
with higher scores indicating more diet self-efficacy.
Exercise self-efficacy. Self-efficacy about enacting an exercise
routine at Time 2 was measured via the Cardiac Exercise Self-Efficacy
Inventory (CESEI; Hickey, Own, & Froman, 1992). The CESEI is a 16-
item scale designed to assess cardiac patients confidence in
implementing and maintaining an active exercise program (e.g.,
exercising for at least 20 minutes three times each week, exercising at
home). Responses to items are made on a 5-point scale (very little
confidence to quite a lot of confidence) and summed, with higher scores
reflecting more exercise self-efficacy.
Experience of cardiac symptoms. Patients experiences of cardiac-
related symptoms at Time 1 and Time 3 were assessed with three
questions adapted from Rose (1962). Participants were asked how many
times during the preceding two weeks they suffered from three common
cardiovascular disease-related symptoms: (a) pain in chest, (b) pressure
or heaviness in chest, and (c) shortness of breath. Responses were made
on a 1 (never) to 5 (more than 15 times) scale and summed, with high
scores indicating more frequent experience of symptoms.

Procedure
Participants were recruited through two Phase II CR programs in a
Midwestern state. These programs typically run for 12 weeks, offering
exercise sessions three times per week (i.e., for a total of 36 sessions
possible), with the total number of sessions often being determined by a
patients insurance company. Patients with more severe diagnoses (e.g.,
coronary artery bypass graft [CABG]) are often approved for more
sessions than patients with less severe conditions (e.g., MI). The time
between patients transitions from hospitalization (i.e., Phase I) to Phase
II varies by the severity of the cardiac event, with entry into Phase II
when exercise does not pose a risk.
Participant recruitment occurred in two phases. First, CR staff
members summarized the studys objectives and procedures during
introductory, intake interviews with new Phase II patients. If patients
provided preliminary written consent, their contact information was
forwarded to our research team. The second phase of recruitment
occurred when our research team members called interested patients.
During phone calls, more detailed information about the study was
provided to patients, and if they expressed interest, a study packet with a
consent form, Time 1 questionnaire, and postage-paid return envelope
was mailed to them. If a patient consented to being in the study, he/she
was asked to sign the consent form and return it, along with the
completed questionnaire, in the enclosed envelope. Signing the consent
Bennett, Adams, & Ricks ATTRIBUTIONAL STYLE 299
form also provided our research team permission to access patients
medical records from their CR programs. Time 2 questionnaires were
mailed to participants 12 weeks later, at the end of their respective Phase
II programs. Time 3 questionnaires were mailed to participants six
months after completion of CR (i.e., nine months following entrance into
CR).
RESULTS
Descriptive statistics for, and correlations among, all study variables
are presented in Table 1, along with coefficient alphas.
2
Table 1 shows
that Time 1 generality scores were positively related to cardiac symptom
experiences at Times 1 and 3, and negatively associated with diet self-
efficacy at Time 2. Internality, however, was unrelated to cardiac
symptoms and both forms of self-efficacy. There was moderate stability
in cardiac symptom experiences between Times 1 and 3, and appraisals
of diet and exercise self-efficacy at Time 2 were moderately correlated.
Both forms of Time 2 self-efficacy were negatively associated with
cardiac symptom experiences at Time 3.

TABLE 1 Descriptive Statistics and Correlations among Study Variables
1 2 3 4 5 6

1. INT, T1

(.51)

.41*

.18

.00

.02

.01
2. GEN, T1 (.80) .27* -.25* -.06 .22*
3. SYM, T1 (.71) -.21* -.09 .61*
4. DSE, T2 (.95) .60* -.44*
5. ESE, T2 (.90) -.29*
6. SYM, T3

(.82)
Mean 27.47 50.74 5.22 57.58 61.62 4.50
SD 6.21 12.33 2.40 13.18 13.20 2.20
Note. INT, T1 = Internality at Time 1; GEN, T1 = Generality Score at Time 1; SYM, T1 =
Cardiac Symptoms at Time 1; DSE, T2 = Diet Self-Efficacy at Time 2; ESE, T2 = Exercise
Self-Efficacy at Time 2; SYM, T3 = Cardiac Symptoms at Time 3. Coefficient alphas are
provided along the diagonal. Probabilities are expressed only to the p < .05 level.
*p < .05.

The studys hypothesis that self-efficacy serves as a mediator of the
relationship between pessimistic attributional stylehere operationalized
as generality scoresand cardiac symptom experiences was tested with
path analysis, using AMOS 19.0. Figure 1 shows results of the model
testing diet self-efficacy as the mediator, controlling for baseline cardiac
symptom experiences. Results showed Time 1 generality scores were
negatively related to Time 2 diet self-efficacy, which, in turn, was
negatively associated with Time 3 cardiac symptom experiences.
300 NORTH AMERICAN JOURNAL OF PSYCHOLOGY
Bivariate analyses showed that baseline generality was significantly
associated with Time 3 cardiac symptoms, but in the path model, this


FIGURE 1 Path Model Testing Time 2 Diet Self-efficacy as a Mediator
of the Relationship between Time 1 Generality Scores and Time 3
Cardiac Symptom Experiences. Model controls for Time 1 Cardiac
Symptoms. *p < .05, ***p < .001.
2
(1) = 2.30, p = .13, NFI = .97, IFI
= .98, CFI = .98, and RMSEA = .02.


association was non-significant. Our model indicated that the total effect
of Time 1 generality scores on Time 3 cardiac symptom experiences was
.083, with an indirect effect via diet self-efficacy of .08. Thus,
approximately 96% of the total effect of baseline generality scores on
cardiac symptoms at Time 3 operated indirectly through diet self-
efficacy. The Sobel (1982) test to examine the significance of the
mediated effect yielded a z = 2.04, p < .05. This model, controlling for
baseline symptoms, explained 42.2% of the variance in Time 3 cardiac
symptom experiences. Findings support the hypothesis that diet self-
efficacy mediates the association between pessimistic attributional style
and cardiac symptom experiences.
Figure 2 shows results of the model testing exercise self-efficacy as
the mediator, controlling for baseline cardiac symptom experiences.
Results showed Time 1 generality scores were unrelated to Time 2
exercise self-efficacy, but that exercise self-efficacy was significantly
associated with Time 3 cardiac symptom experiences. Although we did
not find mediation, the model explained 39.3% of the variance in Time 3
cardiac symptom experiences. Thus, findings do not support the
hypothesis that exercise self-efficacy serves as a mediator of the
relationship between pessimistic attributional style and cardiac symptom
experiences.
Bennett, Adams, & Ricks ATTRIBUTIONAL STYLE 301

FIGURE 2 Path Model Testing Time 2 Exercise Self-efficacy as a
Mediator of the Relationship between Time 1 Generality Scores and
Time 3 Cardiac Symptom Experiences. Model Controls for Time 1
Cardiac Symptoms. **p < .01.
2
(1) = .59, p = .44, NFI = .99, IFI = .99,
CFI = .99, and RMSEA = .001.

DISCUSSION
The purpose of this study was to test self-efficacy as a mediator of the
relationship between pessimistic attributional style and poor health in a
CR sample. Results supported diet self-efficacy as a mediator, but not
exercise self-efficacy. Our findings suggest that the tendency to see
negative events as stemming from stable and global causes is associated
with low confidence in making CR-prescribed dietary changes, but not
associated with confidence in making exercise changes. These results
imply that the exercise education and instruction provided to patients
during CR may be powerful enough to override this maladaptive
cognitive tendency in certain domains. Where the deleterious effects of
pessimistic attributional style may manifest are with confidence levels
surrounding dietary changes. Although CR programs are multi-
disciplinary in nature (Balady et al., 2007), the exercise aspects of the
programs may be most salient to patients. The one-on-one exercise
instruction and feedback provided by CR staff may instill confidence in
patients to maintain healthy exercise habits, but the instruction in dietary
changes may not be intensive enough to overcome the cognitive tendency
to presume independence between actions and outcomes, a hallmark of
pessimistic attributional style.
The interpretation that CR interventions have their most powerful
effects on exercise-related beliefs (as compared to diet-related beliefs) is
supported by the fact that levels of exercise self-efficacy (M = 59.20) and
diet self-efficacy (M = 58.08) prior to CR did not significantly differ
from each other (t [90] = .71, n.s.) in our sample, and by the Time 2
means shown in Table 1. Specifically, a paired-samples t-test showed
302 NORTH AMERICAN JOURNAL OF PSYCHOLOGY
that the two self-efficacy means differed significantly from one another (t
[91] = 3.77, p < .001), with exercise self-efficacy higher than diet self-
efficacy at the end of CR. Thus, our findings suggest that pessimistic
attributional style operates through low confidence to make dietary
changes to affect participants experiences of cardiac-related symptoms
six months later. Our results also support other research documenting the
importance of self-efficacy among CR patients (Burns & Evon, 2007;
Cheng & Boey, 2002; Maddison & Prapavessis, 2004). Regardless of
attributional style, diet and exercise self-efficacy at the end of CR were
negatively related to the experience of cardiac symptoms six months
later.
Theoretically, our findings support others who have downplayed the
importance of the internal dimension of attributional style, in favor of an
examination of the effects of generality scores (derived as a sum of
ratings to the stable and global dimensions; Fresco et al., 2006; Lo et al.,
2010). Mixed results have been reported for the effect of internality on
health outcomes (e.g., Bennett & Elliott, 2005; Hommel et al., 2001), but
not for the effects of the stable and global dimensions. In fact, the stable
dimension has been associated with poor CVD-related outcomes across
multiple studies (e.g., Bennett & Elliott, 2005; Buchanan, 1995; Grewen
et al., 2000). Table 1 shows that Time 1 internality scores were unrelated
to Times 1 and 3 cardiac symptom experiences, as well as to Time 2 diet
and exercise self-efficacy. As it is written, it is impossible to know
whether the self-blame captured by the internal dimension on the ASQ-R
is perceived to be changeable (as with behavioral self-blame) or
unchangeable (as with characterological self-blame). The distinction
between malleable and non-malleable self-blame is an important one
(Janoff-Bulman, 1992), and may shed light on the reasons for the mixed
effects of internality on health outcomes.
Two main implications for practice follow from our results. First, CR
providers should identify people who assign stable and global causes to
negative events. Although we did not examine the relationship between
generality scores and distress (e.g., symptoms of depression and anxiety),
it is likely that the effect of perceived independence between actions and
outcomes goes beyond self-efficacy to other cognitive and affective
constructs, which, in turn, negatively affect health outcomes. Although
attributional style is assumed to be a stable trait, research suggests that it
can be altered through intervention (Peters, Constans, & Matthews, 2011;
Proudfoot, Corr, Guest, & Dunn, 2009). Our data suggest that altering
pessimistic tendencies would benefit health indirectly through its impact
on self-efficacy. Second, CR providers should assess patients self-
efficacy given its strong relationship with health outcomes (e.g., Sarkar et
al., 2009). Identifying patients low in self-efficacy is likely to provide
Bennett, Adams, & Ricks ATTRIBUTIONAL STYLE 303
important information for CR program planning. For example,
identifying patients low in diet self-efficacy, as opposed to low in
exercise self-efficacy, may provide CR staff with information about
where intervention efforts should be targeted. In this case, a patient could
be referred to a nutritionist for additional nutrition counseling to address
low diet self-efficacy. Furthermore, promoting confidence in patients,
regardless of their baseline levels, should promote the enactment of
health-promoting behaviors.
Although this is the first study of which we are aware to examine
self-efficacy as a mediator of the link between pessimistic attributional
style and cardiac symptom experiences, there are limitations worth
noting. First, these data were collected from an ethnically homogenous
and relatively affluent sample of CVD patients participating in a CR
program. Evidence suggests that referral rates to CR are low
(approximately 56%; Brown et al., 2009), and that rates of participation
in CR among eligible patients are even lower (approximately 19%; Suaya
et al., 2007). Therefore, in order to increase generalizability, future
research should recruit a more heterogeneous sample of CVD patients.
Second, all data in this study were collected via self-report, and thus
share common method variance. In addition, self-report data are open to
the hazards of social desirability and other response biases. Negative
affect also is likely to play a role in symptom reporting. To the extent
that pessimistic attributional style contains a component of negative
affect, it is possible that pessimistic individuals report/experience more
CVD-related symptoms than their optimistic counterparts. Therefore,
future research would benefit from clinical assessments of health status,
as well as from cross-informant ratings. Third, although we followed
patients over six months following CR, this is a relatively short period in
a patients recovery process. A longer span between data collection
periods in future studies would allow for the examination of these
processes over a more meaningful period.
In conclusion, beliefs at the beginning of CR that the causes of
negative events are long-lasting and pervasive (i.e., stable and global)
were negatively associated with diet self-efficacy at the end of CR. In
turn, diet self-efficacy was negatively related to cardiac symptom
appraisals six months later. Although diet self-efficacy mediated the
association between generality scores and cardiac symptoms, exercise
self-efficacy was not a mediator. Results showed that both forms of self-
efficacy at the end of CR negatively predicted cardiac symptoms six
months later, supporting prior research. Our results imply that CR
providers should screen for both pessimistic attributional style and self-
efficacy, as interventions to change these constructs may prove fruitful in
the recovery process.
304 NORTH AMERICAN JOURNAL OF PSYCHOLOGY
REFERENCES
Abramson, L.Y., Seligman, M.E.P., & Teasdale, J.D. (1978). Learned
helplessness in humans: Critique and reformulation. Journal of Abnormal
Psychology, 87, 4974.
American Association of Cardiovascular and Pulmonary Rehabilitation. (2004).
Guidelines for cardiac rehabilitation and secondary prevention programs
(4
th
ed.). Champaign, IL: Human Kinetics.
Balady, G.J., Williams, M.A., Ades, P.A., Bittner, V., Comoss, P., Foody, J.M.,
Southard, D. (2007). Core components of cardiac rehabilitation/
secondary prevention programs: 2007 update. Circulation, 115, 2675-2682.
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral
change. Psychological Review, 84, 191-215.
Bennett, K.K., & Elliott, M. (2002). Explanatory style and health: Mechanisms
linking pessimism to illness. Journal of Applied Social Psychology, 32,
15081526.
Bennett, K.K., & Elliott, M. (2005). Pessimistic explanatory style and cardiac
health: What is the relation and the mechanism that links them? Basic and
Applied Social Psychology, 27, 239-248.
Brown, T.M., Hernandez, A.F., Bittner, V., Cannon, C.P., Ellrodt, G., Liang, L.,
Fonarow, G.C. (2009). Predictors of cardiac rehabilitation referral in
coronary artery disease patients: Findings from the American Heart
Association's get with the guidelines program. Journal of the American
College of Cardiology, 54, 515-521.
Buchanan, G.M. (1995). Explanatory style and coronary heart disease. In G.M.
Buchanan & M.E.P. Seligman (Eds.), Explanatory style (pp. 225232).
Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
Buchanan, G.M., Gardenswartz, C.A.R., & Seligman, M.E.P. (1999). Physical
health following a cognitivebehavioral intervention. Prevention and
Treatment, 2. Available: http://psycnet.apa.org/journals/pre/2/1/10a/.
Burns, J.W., & Evon, D. (2007). Common and specific process factors in cardiac
rehabilitation: Independent and interactive effects of the working alliance
and self-efficacy. Health Psychology, 26, 684-692.
Chaney, J.M., Mullins, L.L., Uretsky, D.G., Doppler, M.J., Palmer, W.R., Wees,
S.J., et al. (1996). Attributional style and depression in rheumatoid arthritis:
The moderating role of perceived illness control. Rehabilitation Psychology,
41, 205223.
Cheng, T.Y.L., & Boey, K.M. (2002). The effectiveness of a cardiac
rehabilitation program on self-efficacy and exercise tolerance. Clinical
Nursing Research, 11, 10-21.
Clark, A.M., Hartling, L., Vandermeer, B., & McAlister, F.A. (2005). Meta-
analysis: Secondary prevention programs for patients with coronary artery
disease. Annals of Internal Medicine, 143, 659-672.
Dykema, J., Bergbower, K., Doctora, J.D., & Peterson, C. (1996). An
attributional style questionnaire for general use. Journal of
Psychoeducational Assessment, 14, 100-108.
Dykema, J., Bergbower, K., & Peterson, C. (1995). Pessimistic explanatory
style, stress, and illness. Journal of Social and Clinical Psychology, 14,
357371.
Bennett, Adams, & Ricks ATTRIBUTIONAL STYLE 305
Fresco, D.M., Heimberg, R.G., Abramowitz, A., & Bertram, T.L. (2006). The
effect of a negative mood priming challenge on dysfunctional attitudes,
explanatory style, and explanatory flexibility. British Journal of Clinical
Psychology, 45, 167-183.
Friedman, L.C., Romero, C., Elledge, R., Chang, J., Kalidas, M., Dulay, M.F.,
Osborne, C.K. (2007). Attribution of blame, self-forgiving attitude, and
psychological adjustment in women with breast cancer. Journal of
Behavioral Medicine, 30, 351-357.
Grewen, K., Girdler, S.S., West, S.G., Bragdon, E., Costello, N., & Light, K.C.
(2000). Stable pessimistic attributions interact with socioeconomic status to
influence blood pressure and vulnerability to hypertension. Journal of
Womens Health and Gender-Based Medicine, 9, 905915.
Hickey, M.L., Own, S.V., & Froman, R.D. (1992). Instrument development:
Cardiac diet and exercise self-efficacy. Nursing Research, 41, 347-351.
Hommel, K.A., Chaney, J.M., Mullins, L.L., Palmer, W., Wees, S., & Klein, H.
(2000). The contribution of attributional style to perceived disability in
rheumatoid arthritis: A longitudinal study. Journal of Clinical Psychology
in Medical Settings, 7, 113120.
Hommel, K.A., Wagner, J.L., Chaney, J.M., & Mullins, L.L. (2001). Prospective
contributions of attributional style and arthritis helplessness to disability in
rheumatoid arthritis. International Journal of Behavioral Medicine, 8, 208-
219.
Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of
trauma. New York: Free Press.
Kamen-Siegel, L., Rodin, J., Seligman, M.E.P., & Dwyer, J. (1991). Explanatory
style and cell-mediated immunity in elderly men and women. Health
Psychology, 10, 229235.
Kuttner, M.J., Delamater, A.M., & Santiago, J.V. (1990). Learned helplessness
in diabetic youths. Journal of Pediatric Psychology, 15, 581594.
Levy, B.R., Slade, M.D., & Ranasinghe, P. (2009). Causal thinking after a
tsunami wave: Karma beliefs, pessimistic explanatory style, and health
among Sri Lankan survivors. Journal of Religion and Health, 48, 38-45.
Lin, E.H., & Peterson, C. (1990). Pessimistic explanatory style and response to
illness. Behavioral Research and Therapy, 28, 243248.
Lo, C.S.L., Ho, S.M.Y., & Hollon, S.D. (2010). The effects of rumination and
depressive symptoms on the prediction of negative attributional style among
college students. Cognitive Therapy and Research, 34, 116-123.
Maddison, R., & Prapavessis, H. (2004). Using self-efficacy and intention to
predict exercise compliance among patients with ischemic heart disease.
Journal of Sport and Exercise Psychology, 26, 511-524.
Peters, K.D., Constans, J.I., & Matthews, A. (2011). Experimental modification
of attribution processes. Journal of Abnormal Psychology, 120, 168-173.
Peterson, C. (1995). Explanatory style and health. In G.M. Buchanan & M.E.P.
Seligman (Eds.), Explanatory style (pp. 233-246). Mahwah, NJ: Lawrence
Erlbaum Associates, Inc.
Peterson, C., Buchanan, G.M., & Seligman, M.E.P. (1995). Explanatory style:
History and evolution of the field. In G.M. Buchanan & M.E.P. Seligman
(Eds.), Explanatory style (pp. 120). Mahwah, NJ: Lawrence Erlbaum
306 NORTH AMERICAN JOURNAL OF PSYCHOLOGY
Associates, Inc.
Peterson, C., Seligman, M.E.P., & Vaillant, G.E. (1988). Pessimistic explanatory
style is a risk factor for physical illness: A thirty-five year longitudinal
study. Journal of Personality and Social Psychology, 55, 2327.
Peterson, C., Seligman, M.E.P., Yurko, K.H., Martin, L.R., & Friedman, H.S.
(1998). Catastrophizing and untimely death. Psychological Science, 9, 127
130.
Proudfoot, J.G., Corr, P.J., Guest, D.E., & Dunn, G. (2009). Cognitive-
behavioural training to change attributional style improves employee well-
being, job satisfaction, productivity, and turnover. Personality and
Individual Differences, 46, 147-153.
Roger, V.L., Go, A.S., Lloyd-Jones, D.M., Adams, R.J., Berry, J.D., Brown,
T.M., Wylie-Rosett, J. (2011). Heart disease and stroke statistics2011
update: A report from the American Heart Association. Circulation, 123,
e18-e209.
Rose, G.A. (1962). The diagnosis of ischemic heart pain and intermittent
claudication in field studies. Bulletin of the World Health Organization, 27,
645-658.
Sarkar, U., Ali, S., & Whooley, M.A. (2009). Self-efficacy as a marker of cardiac
function and predictor of heart failure hospitalization and mortality in
patients with stable coronary heart disease: Findings from the Heart and
Soul Study. Health Psychology, 28, 166-173.
Sobel, M. (1982). Asymptotic confidence intervals for indirect effects in
structural equation models. Sociological Methodology, 13, 290-312.
Suaya, J.A., Shepard, D.S., Normand, S.L., Ades, P.A., Prottas, J., & Stason,
W.B. (2007). Use of cardiac rehabilitation by medicare beneficiaries after
myocardial infarction or coronary bypass surgery. Circulation, 116, 1653-
1662.
Sweeney, P.D., Anderson, K., & Bailey, S. (1986). Attributional style in
depression: A meta-analytic review. Journal of Personality and Social
Psychology, 50, 974991.
Taylor, R.S., Brown, A., Ebrahim, S., Jolliffe, J., Noorani, H., Rees, K.,
Oldridge, N. (2004). Exercise-based rehabilitation for patients with CHD:
Systematic review and meta-analysis of randomized controlled trials.
American Journal of Medicine, 116, 682-692.

FOOTNOTES
1
We tested for possible differences between this sample and the larger study from
which it was drawn (n = 155), using t-tests and chi-squares on Time 1
demographic and study variables. Results showed that the groups differed
significantly in age and education: participants in this sample who completed all
three questionnaires were significantly older (M = 63.7) and more educated (M =
5.0) than their counterparts who did not complete all three questionnaires (Ms =
59.7 and 4.5, respectively). These differences warrant some caution in
generalizing findings to all patients in the larger study.
2
For normality purposes, Time 1 and Time 3 cardiac symptom experiences were
subjected to log transformations.
Copyright of North American Journal of Psychology is the property of North American Journal of Psychology
and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for individual use.