Intrinsic Traits Such as Personality and Decision-Making Style are Predictive of Stress in Surrogate Decision-Makers

Abstract

Introduction: Despite its prominence in psychology, little is known about how personality traits play a role in the stress experiences of surrogate decision-makers. We tested the hypothesis that intrinsic traits (personality and decision-making styles) would be related to surrogates’ stress in order to learn whether screening or tailoring interventions based on personality traits could help support surrogate decision-makers. Methods: This pre-specified secondary analysis evaluated data from an interventional study with dyads of patients with advanced chronic illness and their spokespersons. Measures included stress after decision-making or patient death (Impact of Events-Revised), personality (Big Five Index; BFI) and decision-making style (maximization and regret scales). Multivariate linear regressions explored the impact of personality on the stress experience; linear regressions independently modeled the impact of maximization and regret on the stress experience. Results: Of 38 spokespersons, 89.5% were women, 97.4% non-Hispanic, and 29.0% had a college degree or higher. In univariate analyses, total stress was correlated with neuroticism (r = .56, P < .01), higher scores on the regret (r = .55, P < .01) and maximization (r = .48, P < .05). In adjusted models, BFI was significantly associated with total stress (R² = 27.08, P = .02). However, only neuroticism was independently associated with total stress. Conclusions: Personality traits, particularly neuroticism, and decision-making styles predicted heightened stress in spokespersons of patients with advanced chronic illness. If ACP interventions are intended to reduce spokesperson stress, personality and decision-making style scales may help identify spokespersons most likely to benefit from ACP interventions.

Introduction

Advance care planning (ACP) is intended to help patients receive care consistent with their values and preferences during serious illness. ¹ ACP involves designating a spokesperson to make (sometimes stressful) surrogate decisions if a patient cannot do so themself.^1,2 While many ACP interventions have been developed, studies on the benefits have had mixed findings. Several systematic reviews found that ACP yielded no significant differences in patient goal-concordant care or quality of life,^3,4 spurring debate about the very premise and value of ACP. ⁵

We recently completed an eight-year randomized controlled trial that examined the impact of an online ACP decision aid on caregivers’ preparedness to serve as surrogate decision-makers. ⁶ The decision aid was not shown to improve spokespersons’ self-efficacy for surrogate decision-making, however, concordance in clinical vignette responses was higher for those using the decision aid. ⁷ This disconnect between higher concordance but no change in self-efficacy raised questions about how personal factors might affect self-efficacy. ⁷ Further, when qualitative interviews with caregivers subsequently revealed that “intrinsic personality traits” affected their decision-making and stress,^6,8 we added a validated measure to quantitatively evaluate this possible relationship.

Personality, broadly defined, captures an individual’s intrinsic characteristic pattern of thinking, feeling, behavior, and relating across situations and over time. The Big Five trait model has a longstanding history as a valid and reliable conceptualization of personality that is stable over time^9,10 involving five orthogonal factors (extraversion, neuroticism, openness to experience, conscientiousness, and agreeableness). Thus, personality is represented as a range from low levels of a trait to high levels for all five traits, creating an individual’s ‘personality profile’. Extraversion ranges from a reserved disposition, solitary nature, and submission to an energetic disposition, sociability, assertiveness, and positive emotionality. Neuroticism ranges from emotional resiliency and stability to labile and negative emotionality. Openness to experience, or simply openness, ranges from conservativeness, cautiousness, and consistency in perspectives to originality, curiosity, and complexity in perspectives. Conscientiousness ranges from disorganization and carelessness to preparedness, organization, and impulse control. Agreeableness ranges from an aggressive and selfish disposition to a prosocial, communal, and compassionate disposition. As such, each trait captures a pattern of functioning that may predispose an individual to experience a particular thought, feeling, or behavior within a given context, that is, trait engendering a state. Varying degrees of each trait comprise one’s personality.

Although personality is not commonly incorporated into ACP interventions or research, there is substantial research showing how personality traits inform family-centered experiences and outcomes. This research may have applicability for ACP since the stress of serving as a surrogate decision-maker puts one at risk for mental health disorders, including anxiety, depression, and PTSD.^11,12 A review of 175 studies examining relationships between BFI personality traits and mood disorders found that anxiety, depression, and substance use were strongly associated with trait profiles of high neuroticism and low conscientiousness. ¹³ Neuroticism, as a trait, confers a general risk for mental health disorders and myriad physical health concerns,^14-16 in part because high neuroticism is associated with poor responses to stressors, predisposing individuals to greater risk for disorders following a trauma (ie, state).^17-20 It’s probable that a caregiver with lower levels of neuroticism would be characteristically predisposed to approach end-of-life decision-making with emotional resiliency while a caregiver with higher levels of neuroticism would likely be more susceptible to negative emotionality. Higher levels of conscientiousness are associated with positive physical health outcomes ²¹ and coping strategies that protect against maladaptive responses following stressors.^22-24 Thus, a caregiver with higher levels of conscientiousness would be characteristically predisposed to approach end-of-life decision-making with preparedness while a caregiver with lower levels of conscientiousness would be characteristically predisposed to approach end-of-life decision-making with disorganization.

Recent qualitative research emphasizes that personality traits play an important role in selection of spokespersons during end-of-life decision-making.^6,8,25 But despite its prominence in clinical, social, and personality psychology, there has been little exploration of personality traits’ relation to surrogate decision-making and ACP-related stress.

The present analysis explored whether intrinsic traits (eg, personality, decision-style) are related to stress experienced by spokespersons involved in surrogate decision-making for patients with advanced illness. We hypothesized that higher scores on the neuroticism scale would be associated with higher levels of stress after decision-making or patient death, and that higher scores on the conscientiousness scale would be associated with lower levels of stress. We also hypothesized that higher scores on regret and maximization scales would be predictive of the stress experience.

Methods

Parent Study and Participants

This secondary analysis involves data collected during a randomized controlled trial that compared two ACP interventions on spokesperson preparedness to serve as a surrogate decision-maker, each of which was either completed by the patient alone, or together with their spokesperson (methodology and results reported elsewhere).^6-8 All four groups completed ACP and there were no substantial differences in their respective stress outcomes. ⁸ Hence, for this analysis all participant data were aggregated.

After providing written informed consent, adult patients with advanced illness and their spokespersons were enrolled as dyads from tertiary care settings in (primarily rural)Hershey, Pennsylvania and (primarily urban) Boston, Massachusetts. Dyads were randomized based on spokesperson gender, site, and diagnosis using a stratified permuted block design. ⁷ The trial was approved by the Institutional Review Board and registered at clinicaltrials.gov (NCT02429479).

Adult patients (>18 years old) were eligible if they had a diagnosis of: (a) advanced cancer (Stage IV disease or having an estimated survival of <2 years); (b) advanced lung disease (Stage III or IV chronic obstructive pulmonary disease); (c) Class II or IV advanced heart failure, or (d) chronic kidney disease/end-stage renal disease. Additional inclusion criterion included: ability to read English at an eighth grade level, a Mini-Mental State Examination score >23, and no active suicidal ideations. Adult caregivers were eligible if they were identified by the patient as their chosen surrogate decision-maker and had in-person interaction with patient at least weekly. One surrogate was chosen per patient participant.

The parent trial involved three study visits. At Visit 1, dyads completed baseline questionnaires, were randomized, and completed an ACP interventional arm. At Visit 2 four weeks later, dyads completed questionnaires and spokespersons participated in semi-structured interviews to explore their self-efficacy to serve as a surrogate decision-maker. After Visit 2, spokespersons were interviewed by phone to assess whether a surrogate decision had been made (or if the patient had died since last contact). If a surrogate decision or death was reported, a third visit was conducted to interview participants and administer questionnaires. This paper focuses on our secondary analysis of findings from Visit 3.

Measures

Subjective Stress: Impact of Event Scale-Revised

The main outcome was spokespersons’ subjective stress (measured using the IES-R), a validated 22-item questionnaire that screens for symptoms of stress-related disorders including post-traumatic stress disorder (PTSD).^26,27 It is considered a core outcome in studies of stress after surrogate decision-making. ²⁸ Each item is scored from 0 to 4; total scores ranges 0-88. Total scores of 24-33 suggests a strong association with subthreshold symptoms of PTSD, while scores >33 are associated with PTSD, and scores >37 are associated with prolonged immune suppression.^26,27 The measure’s three subscales (Intrusion, Avoidance, and Hyperarousal) help delineate varied stress responses as follows: intrusion (intrusive thoughts, nightmares, intrusive feelings and images, dissociative-like re-experiencing), avoidance (numbing of responsiveness, avoidance of feelings, situations, and ideas), and hyperarousal (anger, irritability, hypervigilance, difficulty concentrating, or a heightened startle response).^27,29

Personality Traits: The Big Five Inventory

Surrogates’ personality traits were identified using the BFI, ³⁰ a highly validated and reliable 44-item measure of the five main domains that correspond to characteristic thoughts, feelings, and behaviors. ³⁰ Items begin with “I see myself as someone who,” and participants use a 5-point Likert scale to indicate their level of agreement with each characteristic (1 = disagree strongly; 5 = agree strongly). The BFI assesses the domains of extraversion (eg, “I see myself as someone who is talkative”), neuroticism (eg, “I see myself as someone who gets nervous easily”), openness to experience (eg, “I see myself as someone who is original and comes up with new ideas”), agreeableness (eg, “I see myself as someone who likes to cooperate with others”), and conscientiousness (eg, “I see myself as someone who makes plans and follows through with them”). Main domain scores of extraversion, neuroticism, openness to experience, agreeable, and conscientiousness are computed as averages of scale-specific item responses. The average score of the items for each domain creates a scaled score ranging from 1-5, with higher scores corresponding to greater levels of that specific personality trait. Important to note is that the term ‘neuroticism’ is a commonly used term in the field of psychology, and is not intended to be stigmatizing towards patients as it is simply a personality trait, and some (if not all) individuals possess some level of neuroticism; it is the varying degrees of this trait that makes up one’s personality profile.

Decision-Making Style

Surrogates’ decision-making style was represented using two validated measures. The maximization scale is a 6-item measure that examines the extent to which individuals make decisions by either searching for and choosing the ‘best’ options vs tending to ‘satisfice’ with options they consider ‘good enough’. ³¹ An example of an item on the maximization scale is, “Renting videos is really difficult. I’m always struggling to pick the best one.” Research has shown that being a maximizer correlates with higher levels of regret and dissatisfaction compared to being a ‘satisficer,’ and that maximizers are less happy, less optimistic, and more depressed than satisficers.^32,33 The maximization scale ranges from 7 to 42, with items anchored by 1 (completely disagree) to 7 (completely agree), and 42 being the highest maximization score.

The regret scale is a validated 5-item questionnaire that measures the tendency to experience regret after decision-making, ³³ which is positively correlated with maximization and depression. ³³ Measures range from 5 to 35 (with 5 items scored on a 7-point Likert scale), with 35 being those with the highest tendency towards regret after decision-making. An example of an item on the scale is, “I regret the choice that I made.”

For both scales, the summed scores were converted to a 1-5 metric to be consistent with previously reported samples. ³¹

Statistical Analyses

All analyses were performed using R software, version 3.6.1. ³⁴ Preliminary power analyses illustrated that a sample of 38 would have sufficient power to capture large effect sizes. Bivariate Pearson correlations were used to explore independent associations among variables of interest. Multivariate linear regressions including all personality variables as predictors were implemented to explore the impact of personality on the experience of stress. Linear regressions were used to model the impact of regret and decision-making style on the experience of stress. Multicollinearity was tested via tolerance, variance inflation factor (VIF), and correlations such that tolerance <.10, VIF >4, or r > .90 would suggest multicollinearity. ³³ Residual diagnostics were conducted to test for violations of assumptions of normality and heteroscedasticity. ³³ Thus, a studentized deleted residual >3, leverage value >1, or Cook’s D residual >.47 would suggest a violation of normality assumptions. Variance explained by the model was quantified via adjusted R ² .

Results

Participant Demographics

Participants in this sample included those who completed the study measures added for this secondary analysis (n = 38; Figure 1 for consort diagram, Table 1 for demographics). Participants were predominantly female (89.5%) and non-Hispanic (97%). All variables, including personality traits, were normally distributed (see Table 2) under conventional thresholds.^35,36

Figure 1.

Consort diagram demonstrating how the analytic sample was generated from the parent randomized controlled trial.

Table 1.

Demographics of Spokespersons.

Characteristics	Spokespersons (n = 38)
Gender, female n (%)	34 (89.5)
Age in years, mean (SD) a	61.4 (12.0)
Race/ethnicity, n (%) b
Hispanic or Latino	0 (0)
Black or African American	10 (26.3)
White	28 (73.7)
Patient’s primary disease category, n (%)
Cardiac	12 (32.0)
Pulmonary	9 (23.7)
Renal	9 (23.7)
Cancer	8 (21.1)
Education, n (%)
High school graduate or GED	9 (23.7)
Some college or technical school	18 (47.4)
College graduate	8 (21.1)
Graduate or professional school	3 (7.9)
Current marital status, n (%)
Never married	3 (7.9)
Married	31 (81.6)
Divorced or legally separated	3 (7.9)
Domestic partnership	1 (2.6)
Current employment status, n (%)
Employed part-time	4 (10.5)
Employed full-time	15 (39.5)
Not currently employed and not seeking work	5 (13.2)
Not currently employed but seeking work	3 (7.9)
Retired	9 (23.7)
Other	2 (5.3)

^aAge at the time of V3.

^bOne participant did not respond.

Table 2.

Descriptive Statistics Reporting Responses on the Intrinsic Traits of Participants.

	N	Mean (SD)	Median	Skew	Kurtosis	SE
Impact of events scale
Stress: Total (range) a	31	31.81 (14.85)	28.00	.15	−1.10	2.67
Intrusion	31	14.16 (6.69)	14.00	.18	−.63	1.2
Avoidance	30	9.17 (5.32)	8.00	.27	−1.12	.97
Hyperarousal	30	9.07 (5.56)	8.50	.23	−1.06	1.02
Big five inventory (1 = low trait levels; 5 = high trait levels) b
Neuroticism	37	2.79 (.89)	2.75	−.05	−.98	.15
Extraversion	37	3.45 (.64)	3.50	−.11	−.67	.11
Agreeableness	37	4.31 (.62)	4.56	−.97	−.01	0.1
Conscientiousness	37	4.04 (.61)	4.00	−.68	−.09	0.1
Openness	37	3.71 (.68)	3.70	−.01	−1.03	.11
Decision-making style scale
Regret scale	33	12.84 (4.20)	13.00	−.21	−.86	.73
Maximization scale	33	15.56 (3.14)	15.33	0.1	−.84	.55

SD = Standard deviation; SE = Standard error.

^aScores of >33 represent probable post-traumatic stress disorder.

^bSince traits typically follow a normal distribution, a mean score of 2.5 suggests a moderate ‘level’ for each trait.

Correlation Analyses: Relationships Between Stress, Personality Traits, and Decision-Making Style.

Table 3 shows associations between intrinsic characteristics (personality traits and decision-making style) and stress. Neuroticism was strongly associated with stress in the hyperarousal domain (r = .69, P < .001) and moderately associated with total stress (r = .56, P = .001) and the intrusion domain (r = .52, P = .003). Low to moderate correlations were seen with other personality traits. Regret was moderately associated with total stress (r = .55, P = .003) and hyperarousal domain (r = .49, P = .009).

Table 3.

Correlations Among Personality Traits, Decision-Making Style With Stress Scores.

	IES-Total	IES-Intrusion	IES-Avoidance	IES-Hyperarousal
Personality traits
Neuroticism	.56**	.52**	.27	.69***
Extraversion	−.18	−.10	−.34	−.11
Agreeableness	−.29	−.21	−.38*	−.40*
Conscientiousness	−.23	−.22	−.20	−.35
Openness	−.15	−.11	−.34	−.06
Decision-making style
Regret scale	.55**	.47*	.48*	.49**
Maximization scale	.48*	.43*	.46*	.45*

IES = impact of event scale.

*p < .05; **p < .01; ***p < .001.

Regression Models

Table 4 summarizes results from the multivariate linear regression and linear regression models that regressed the intrinsic traits (the 5 personality traits and 2 decision-styles, regret and maximization) to the scores on the IES scale and subscales.

Table 4.

Summary of Findings From Multiple and Linear Regression Models.

Measure	IES Scale (Range 0-)	Adjusted R 2 a	P value	IES Score for Every 1 Point Increase of Interest (B)	P value
Big five index				Neuroticism
	IES-Total	27.08	.02	10.50	.002
	IES-Intrusion	17.43	.07	4.33	.006
	IES-Avoidance	21.08	.055	1.83	.121
	IES-Hyperarousal	43.12	.002	3.76	<.001
Regret scale				Regret
	IES-Total	27.70	.003	2.01	.003
	IES-Intrusion	18.90	.01	2.66	.01
	IES-Avoidance	19.70	.01	.59	.01
	IES-Hyperarousal	21.20	.01	.68	.01
Maximization scale				Maximization
	IES-Total	20.10	.011	2.36	.011
	IES-Intrusion	15.00	.03	.95	.03
	IES-Avoidance	17.90	.018	.81	.018
	IES-Hyperarousal	17.40	.017	.85	.017

^aAdjusted R ² reflects the improvement in model fit when intrinsic traits are added, relative to an intercept-only model. Unstandardized beta coefficient (B) illustrates the direct impact of variables of interest on the experience of stress.

Multivariate Linear Regression

Personality Traits and IES Scores (summarized in Table 4)

Total Stress

A model including all personality traits significantly predicted the total (summative) stress score, F (5, 25) = 3.23, P = .02, accounting for 27.08% of the variance. When all personality traits are taken into account, only neuroticism independently associates with total (summative) stress such that a 1 unit increase in neuroticism results in a 10.50 increase in total (summative) stress t (25) = 3.49, P = .002.

Stress Subscales (summarized in Table 4)

IES-Intrusion

A model including all five personality traits did not significantly predict scores on the IES-intrusion subscale, F (5, 25) = 2.27, P = .07, accounting for 17.43% of the variance of IES-Intrusion stress scores.

IES-Avoidance

A model including all 5 personality traits did not significantly predict avoidance, though it did approach significance, F (5, 24) = 2.55, P = .055, accounting for 21.08% of the variance of IES-Avoidance stress scores.

IES-Hyperarousal

A model including all personality traits significantly predicted hyperarousal, F (5, 24) = 5.40, P = .002, accounting for 43.12% of the variance in IES-hyperarousal scores. Controlling for all other 4 personality traits, only neuroticism significantly predicted hyperarousal such that a 1 unit increase in neuroticism results in a 3.76 increase in arousal t (24) = 3.77, P < .001.

Linear Regressions: Decision-Making Style (Regret Scale) and IES Scores (Summarized in Table 4)

Total Stress

A model including regret as the sole predictor significantly predicted the total level of stress, F (1, 25) = 10.97, P = .003, accounting for 27.70% of the variance, such that a 1 unit increase in regret results in a 2.01 increase in total level stress, t (25) = 3.31, P = .003.

Stress Subscales

IES-Intrusion

A model including regret significantly predicted intrusion, F (1, 25) = 7.05, P = .014, accounting for 18.90% of the variance, such that a 1 unit increase in regret results in a .77 increase in intrusion, t (25) = 2.66, P = .01.

IES-Avoidance

A model including regret significantly predicted avoidance, F (1, 24) = 7.14, P = .01, accounting for 19.70% of the variance, such that a 1 unit increase in regret results in a .59 increase in avoidance, t (24) = 2.67, P = .01.

IES-Hyperarousal

A model including regret significantly predicted hyperarousal, F (1, 25) = 7.99, P = .009, accounting for 21.20% of the variance, such that a 1 unit increase in regret results in a .68 increase in hyperarousal, t (25) = 2.82, P = .009.

Linear Regressions: Decision-Making Style (Maximization Scale) and IES Scores (Summarized in Table 4)

Total Stress

A model including decision-making style significantly predicted total level of stress, F (1, 25) = 7.52, P = .011, accounting for 20.10% of the variance, such that a 1 unit increase in maximization results in a 2.36 increase in total level of stress, t (25) = 2.74, P = .011.

Stress Subscales

IES-Intrusion

A model including decision-making significantly predicted intrusion, F (1, 25) = 5.59, P = .03, accounting for 15.00% of the variance, such that a 1 unit increase in maximization results in a .95 increase in intrusion, t (25) = 2.36, P = .03.

IES-Avoidance

A model including decision-making significantly predicted avoidance, F (1, 24) = 6.44, P = .018, accounting for 17.90% of the variance, such that a 1 unit increase in maximization results in a .81 increase in avoidance, t (24) = 2.54, P = .018.

IES-Hyperarousal

A model including decision-making significantly predicted hyperarousal, F (1, 25) = 6.48, P = .017, accounting for 17.40% of the variance, such that a 1 unit increase in maximization results in a .85 increase in hyperarousal, t (25) = 2.55, P = .017.

Discussion

Because surrogate decision-makers for patients with advanced illness are at risk for stress-related disorders including post-traumatic stress disorder (PTSD),^11,37 this study examined whether spokespersons’ intrinsic personality and decision-making traits are related to such outcomes. We found that personality traits (particularly neuroticism) and decision-making styles (regret and maximization) appear to predict heightened stress experiences. This was especially true for neuroticism, with a 1-point increase on the neuroticism subscale corresponded to a 10-point increase in IES-R score. This is clinically meaningful because a 10-point magnitude can help distinguish an individual with stress equivalent to subthreshold PTSD (score of 24) from probable PTSD (score of 33). ²⁷

Our finding demonstrated that those with higher neuroticism scores are at increased risk of poor psychological outcomes and may benefit from targeted interventions for reducing stress. Even though intrinsic personality traits may not be explicitly modifiable, knowing which participants have at-risk traits could be useful for tailoring interventions for trait profiles. These findings also raise the possibility that previous negative ACP trial results are due in part to inclusion of participants less likely to actually need an ACP intervention.

Extensive research in clinical psychology has established the importance of neuroticism in understanding mental and physical health. Individuals with high neuroticism are characteristically predisposed to experience a range of negative affectivity, including anxiety, irritability, and emotional instability. ¹⁶ Neuroticism has been shown to be a prominent dimension related to internalizing mood disorders. ³⁸ Increased anxiety and depression following life stressors ¹⁶ are thought to be due to a disposition to strongly experience negative affect and negative cognitive biases. ²² Because of these strong association between neuroticism and negative outcomes, it has been recommended that routine medical care include screening for clinically significant levels of neuroticism.^16,39

Individuals high in neuroticism tend to appraise events as highly threatening, and lack effective coping strategies, which can exacerbate negative emotional reactivity.^40,41 Such individuals also tend to engage in wishful thinking, withdrawal, and emotion-focused coping strategies that are detrimental for surrogate decision-making.^40-42 Accordingly, one could imagine ACP interventions including branching logic to provide coping and planning strategies for individuals with high neuroticism ⁴³ or provide decisional supports for decision maximizers and individuals prone to post-decision regret. It is important to note that traits (such as neuroticism) engender ‘states’ (eg, difficulty coping or experiencing grief). Thus, an acute stressful experience does not confer the enduring personality trait of neuroticism. Rather, higher neuroticism represents a patterned tendency to respond to most situations with increased stress, difficulty coping, and grief. Thus, a person higher in neuroticism is predisposed to experience significant negative outcomes following a stressful experience (end of life decision making). In other words, a trait begets a state, though one state does not beget a trait.

Limitations to this study include its small, non-diverse, and female predominant sample. Further, because research questions emerged during the course of the study, the sample was underpowered, and so some relationships between variables may not have achieved significance. Additionally, due to nature of the Visit 3 (which required a surrogate decision to have been made and/or death of the patient), the data were not collected at a uniform timepoint for all participants. While intrinsic traits are typically unchanging over time, it is possible that differences in data collection may have weakened expected associations with stress over time. Moreover, there were 11 participants who did not make a surrogate decision because patients died without any surrogate decisions.

Despite these limitations, study strengths included that the sample was derived from a large randomized controlled trial that assessed responses to actual decisions (or death) rather than hypothetical scenarios, and employed well-validated study measures with strong psychometrics. Further, in light of recent controversy about the benefits and shortcomings of ACP, the present findings provide evidence that considering intrinsic traits of surrogate decision-makers could result in more effective ACP for the people who are more likely to benefit from it. As such, inter-disciplinary collaboration with social scientists who study personality traits could yield significant advances in the design and implementation of interventions for medical decision-making.

Implications for Clinical Practice

Our findings may be useful for considering how best to prepare and support family members for surrogate decision-making. Specifically, if some ACP interventions are effective for certain personality types but not others, then screening for personality traits could help identify those most likely to benefit from ACP interventions. Relatedly, considering personality traits when designing the interventions themselves could help target specific needs. For example, problems with emotional dysregulation among individuals with higher neurotic traits could be addressed focused on psychological support intervention (rather than cognitive-based interventions). While additional research is needed to help determine how interventional design can best take personality traits into account, the present findings suggest that BFI could be a useful screening tool for identifying individuals with personality types more likely to respond to tailored interventions. Future studies should further characterize this relationship and seek to examine how personality traits are related to commonly used clinical tools that screen for psychological symptoms of anxiety and depression.

ORCID iD

Lauren J. Van Scoy https://orcid.org/0000-0003-0984-1474