Original Article

A cross-sectional population-based study on the

association of personality traits with anxiety and
psychological stress: Joint modeling of mixed
outcomes using shared random effects approach
Awat Feizi1,2, Ammar Hassanzadeh Keshteli3, Fatemeh Nouri1,4, Hamidreza Roohafza2, Peyman Adibi5
1
Department of Biostatistics and Epidemiology, School of Health, 2Psychosomatic Research Center, Isfahan University of Medical Sciences,
Isfahan, Iran, 3Department of Medicine, University of Alberta, Edmonton, Alberta, Canada, 4Isfahan Cardiovascular Research Center,
Cardiovascular Research Institute, Isfahan University of Medical Sciences, 5Department of Internal Medicine, School of Medicine and
Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Background: Previous studies have showed some evidences about the relationship between personality traits particularly
neuroticism and extroversion, separately, with psychological stress and anxiety. In the current study, we clarified the magnitude
of joint interdependence (co-morbidity) of anxiety (continuous) and Psychological stress (dichotomous) as dependent variables of
mixed type with five-factor personality traits as independent variables. Materials and Methods: Data from 3180 participants who
attended in the cross-sectional population-based “study on the epidemiology of psychological, alimentary health and nutrition” and
completed self-administered questionnaires about demographic and life style, gastrointestinal disorders, personality traits, perceived
intensity of stress, social support, and psychological outcome was analyzed using shared random effect approach in R Free software.
Results: The results indicated high scores of neuroticism increase the chance of high psychological stress (odds ratio [OR] = 5.1; P
< 0.001) and anxiety score (B = 1.73; P < 0.001) after adjustment for the probable confounders. In contrast, those who had higher
scores of extraversion and conscientiousness experienced lower levels of anxiety score (B = −0.54 and −0.23, respectively, P < 0.001)
and psychological stress (OR = 0.36 and 0.65, respectively, P < 0.001). Furthermore, higher score of agreeableness had significant
negative relationship with anxiety (B = −0.32, P < 0.001). Conclusion: The present study indicated that the scores of neuroticism,
extraversion, agreeableness and conscientiousness strongly predict both anxiety and psychological stress in Iranian adult population.
Due to likely mechanism of genetic and environmental factors on the relationships between personality traits and psychological
disorders, it is suggested to perform longitudinal studies focusing on both genetic and environmental factors in Iranian population.

Key words: Anxiety, psychological stress, personality traits, shared random effect model, mixed outcomes

How to cite this article: Feizi A, Keshteli AH, Nouri F, Roohafza H, Adibi P. A cross-sectional population-based study on the association of personality
traits with anxiety and psychological stress: Joint modeling of mixed outcomes using shared random effects approach. J Res Med Sci 2014;19:834-43.

INTRODUCTION both developing and developed countries and varied

with age and job for both men and women. [7,9] In
Mental illness has an impact on every aspect of life, general, 28-39% of Iranian adult population suffered
including physical health and risk behavior.[1] Anxiety from possible psychological stress as measured by the
disorders are the most prevalent among all mental General Health Questionnaire (GHQ)-12.[10]
illnesses.[2,3] General somatic symptoms that occur with
anxiety are fatigue and loss of energy, feeling slowed Over the past 60 years, there has been increasing interest
up or agitated impaired physical, role functioning and in normal personality traits and their relationship
restless.[4,5] In Iranian normal population, the prevalence to “neurosis.”[11] Personality traits are dimensions of
of anxiety is 20.8% among urban and rural dwellers in individual differences that can affect a wide range
age group 15 years above.[6] of behaviors across many situations. [12] In the past
20 years, a growing consensus has supported the five-
There is evidence to suggest that stress is related to factor model (FFM) as a reasonably comprehensive yet
impoverished mental health.[7] Stress is also one of the manageable taxonomy of personality traits. The FFM
leading predisposing factors in the development of is a hierarchical model that organizes personality traits
mental disorders.[8] The prevalence of stress is high in into five broad or higher-order factors of neuroticism,

Address for correspondence: MSc, Fatemeh Nouri, Department of Biostatistics and Epidemiology, School of Health and Isfahan Cardiovascular
Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: noori.hengameh@gmail.com
Received: 05‑05‑2014; Revised: 31‑05‑2014; Re-revised: 29-06-2014; Accepted: 16-10-2014

| September 2014 | Journal of Research in Medical Sciences 834

 Feizi, et al.: The association of personality traits with anxiety and psychological stress

extraversion, agreeableness, conscientiousness and is, neuroticism and extraversion. Additionally, these studies
openness to experience. [13] Neuroticism reflects one’s have been limited to some specific population such as
tendency to experience negative emotions and cope poorly, patients and college students and hence that it is unclear
extraversion indicates one’s tendency to be sociable and to what extent their findings are applicable to the general
active, agreeableness, one’s orientation toward others; population. On the other hand, majority of the conducted
conscientiousness, one’s organization, motivation and previous studies have used simple statistical methods, and
persistence in achieving goals and openness to experience they did not adjust the impacts of possible confounders.
reflects one’s appreciation of experience for its own sake.[14]
The main objective of current study was to investigate the
There are evidences establishing that the personality relationships between psychological stress and anxiety with
traits particularly neuroticism and extraversion have five-factor personality traits controlling for the impacts of
important links to psychopathology and are also important some important possible confounders including sex, age,
vulnerability factors for anxiety disorders that at least marital status, education level, body mass index (BMI),
partly responsible for the co-morbidity among mental perceived intensity of stress, social support, smoking
disorders. Available evidence suggested these two domains behavior, physical activity, number of FGIDs using a
(personality and psychopathology) are intrinsically inter- comprehensive statistical method in a large sample of
correlated, such that neither can be fully appreciated without Iranian adults.
the other.[15] Stress and anxiety scores were significantly and
positively correlated with neuroticism scores and were also MATERIALS AND METHODS
negatively correlated with extraversion scores in both men
and women in the general population. The personality Study population and setting
characteristic of neuroticism was a predisposing factor for The current study is a part of the “study on the
stress and anxiety.[7,14] Neuroticism and introversion are epidemiology of psychological, alimentary health and
associated with greater prevalence of anxiety disorders.[14,16] nutrition” (SEPAHAN).[20] In this cross-sectional study,
Also, there is evidence that lower-order dimensions of the studied sample was selected using multistage cluster
agreeableness and facets of conscientiousness have been sampling and convenience sampling in the last stage
linked to some anxiety disorders.[14,17] Personality traits of among 4 million people in 20 cities across Isfahan province.
patients with a mental disorder differ significantly from the In SEPAHAN study, data were collected in two separate
general population.[18] Individual with higher neuroticism phases to increase the accuracy as well as the response rate.
and lower extraversion scores experience higher stress and In the first phase, all participants were asked to complete
anxiety scores[7,19] a self-administered questionnaire about demographic
and lifestyle factors including nutritional habits and
The relation between personality traits and mental problems dietary intakes. In the second phase, further information
could be affected by unhealthy lifestyle factors including on gastrointestinal functions and different aspects of
inadequate physical activity, smoking and some physical psychological variables were collected using another
illness such as functional gastrointestinal disorders bunch of self-administered questionnaires (response rate:
(FGIDs).[20-22] In this regard, also, the key role of some other 86.16%). In the current analysis, we used data from 4,763
background confounders such as educational level,[23,24] adults who had completed data on demographic data,
marital status,[25] age,[6,10,26] sex,[14,27,28] Perceived intensity of personality traits, perceived intensity of stress, social
stress[10,29] and obesity[30] can be considered. support, and psychological outcome such as stress and
anxiety. The protocol of the study was clarified for all the
Investigation of relations between personality traits participants, and a written informed consent was obtained
and high-prevalence mental problems can provide from all participants. The ethics committee of Isfahan
important information on the dimensional measures of University of medical sciences approved the study. Finally,
psychopathology and screen for psychological factors in the information from 3180 people who provided complete
the primary care settings. Such researches can provide a information on all studied variables in the current study
somewhat clear prospective on the relationship between was included in analyses.
personality traits and psychopathology and finally will
enhance our knowledge about psychological problems Assessment of psychological variables
and lead to improvement in mental and physical health. Psychological stress
Majority of previous studies on the relationships between Psychological stress was measured by a self-administered
personality traits and mental problems, in one hand, have 12-item GHQ-12, a well-established screening and
focused only one problem, and in the other hand, have diagnostic tool to detect nonpsychotic psychiatric
emphasized only two of the five higher-order factors, that disorders and assessing psychological stress.[31,32] GHQ-12

835 Journal of Research in Medical Sciences | September 2014 |

 Feizi, et al.: The association of personality traits with anxiety and psychological stress

is a consistent and reliable instrument for using in general were found 0.86, 0.77, 0.73, 0.68, and 0.81 for N, E, O, A
population studies and medical settings.[33] Participants and C, respectively.[35] In Iranian population, Cronbach’s
report having experienced a particular feeling or type alpha is shown for neuroticism, extraversion, openness,
of behavior ‘less than usual, no more than usual, fairly agreeableness and conscientiousness as 0.76, 0.65, 0.59, 0.48
more than usual, or much more than usual’ in the past and 0.75, respectively.[36]
few weeks. A participant could score between 0 and 12
points, and a threshold score of 4 or more was used to Assessment of other variables
identify a participant with high-stress level.[25] The internal Self-administered standard questionnaires were distributed
consistency of GHQ-12 calculated with Cronbach’s alpha to collect information on age (years), gender (male/female),
coefficient was found 0.87. Convergent validity indicated marital status (married, single), self-reported weight (kg),
a significant negative correlation between the GHQ-12 height (cm), smoking (none, former and current smokers).
and global quality of life scores as r = −0.56, P < 0.0001 in BMI was calculated by dividing weight in kilograms
Iranian population.[33] by height in meters squared. Educational attainments
categorized into three categories as lower than diploma
Hospital Anxiety and Depression Scale (12 years formal education), diploma and more than
Hospital Anxiety and Depression Scale is a standardized, diploma (including bachelor, master and doctorate). Self-
valid, and reliable self-report rating scale. HADS has been reported history of major FGIDs including gastroesophageal
extensively tested and has well-established psychometric acid reflux disease (GERD), functional dyspepsia (FD),
properties. It consists of 14 items: Seven for anxiety functional constipation (FC) and irritable bowel syndrome
(HADS-anxiety). It was answered using a 4-point Likert (IBS) was explored. The Rome III questionnaire in its
scale ranging from 0 (not present) to 3 (considerable). The complete form and additional questions from the Talley
anxiety score is the summation of the particular seven items Bowel Disease Questionnaire were used to diagnose
(ranging from 0 to 21). The ranges of anxiety score for cases and classify FGIDs. Face validation of this questionnaire
are 0-7 normal, 8-21 mild, moderate or severe disorder. indicated that most participants could not discriminate
Internal consistency as measured by Cronbach’s alpha has the difference between the rating scales used in Rome
been found to be 0.78 for HADS anxiety sub-scale in Iranian III. Therefore, rating scales were modified to a 4-item —
population.[34] rating scale (never or rarely, sometimes, often, always) for
each question. Details of some changes in Rome III were
Assessment of personality traits described in former publications.[20] In the current study,
As earlier indicated the FFM has been increasingly the number of FGIDs was considered (Ranging from 0 to
recognized as a comprehensive, robust and parsimonious 4). Perceived intensity of stress was measured using a self-
model of normal personality traits and had strong external administered stressful life events questionnaire (SLE). The
empirical support.[16] Among the available instruments for questionnaire has 46 items having 11 various dimensions
measuring five-factors, the NEO Five-Factor Inventory including home life, financial problems, social relation,
(NEO-FFI) and the NEO Personality Inventory Revised personal conflicts, job conflicts, educational concerns, job
(NEO-PI-R) are the most widely used. NEO-FFI was security, loss and separation, sexual life, daily life, and
a shortened version of the NEO-PI-R (240-items). The health concerns. Each domain was assessed with a specific
NEO-FFI results in a profile of the personality of the number of items using a five-point response scale (“strongly
subject and consists of 60 self-descriptive statements disagree — strongly agree”). SLE questionnaire has been
about the personality that measuring five dimensions of validated in an Iranian general population.[37] Perceived
the normal personality (i.e., neuroticism, extraversion, social support was measured using Multidimensional
openness, agreeableness and conscientiousness) and Scale of Perceived Social Support (MSPSS) that consisted
consisting 12 item/dimension. Respondents indicate the of 12 specific questions and 3 sources of support: Family,
degree to which they agree or disagree with each of the friends, and significant other.[38] In the current study, the
statement using a five-point Likert-type scale (0 = strongly rescoring form of MSPSS has been used; in which, each
disagree, 4 = strongly agree). Eight items required reverse item scored from 0 (disagree and neutral) to 1 (agree), led
scoring. Individual subscale values were determined by to a total score between 0 and 12. Higher score represents
summing the 12 items.[18] Evidences suggested that the higher social support. Validity and reliability of the scale has
shortened tool of NEO-FFI is exactly compatible with been evaluated in Iran.[39] General Practice Physical Activity
its complete form namely NEO-PI-R so that correlations Questionnaire (GPPAQ) was used to assess an individual’s
between the NEO-FFI and the longer NEO PI-R domains current physical activity status. The GPPAQ consists of work
were 0.92, 0.90, 0.91, 0.77, and 0.87 for N, E, O, A, and C, and leisure time physical activity. It generates simple, 4-level
respectively. Internal consistency coefficients for the NEO- Physical Activity Index categorizing subjects as: Active,
FFI scales calculated with Cronbach’s alpha coefficient moderately active, moderately inactive, and inactive.[40]

| September 2014 | Journal of Research in Medical Sciences 836

 Feizi, et al.: The association of personality traits with anxiety and psychological stress

In the current analysis, participants were classified into percentage of men with high stress level that is, 27.7% versus
two categories namely inactive (including inactive and 18.8% (P < 0.001). The prevalence of GHQ’s score 4 and higher
moderately inactive) and active (including moderately was 34.4%, 24.1% and 21.9% in individuals with 0-12, 12 and
active and active as earlier indicates). more than 12 years of education, respectively (P < 0.001). In
general, in the studied population, 26.5% of inactive and 21.0%
Statistical analysis of active subjects had GHQ score 4 and higher (P < 0.001).
Data were analyzed by R Free Statistical Software version Suffering from a different number of FGIDs was associated
2.15.1. Results were presented as mean ± standard deviation with an increased prevalence of high psychological stress
(SD) for quantitative variables and were summarized among study subjects. In the other words, the prevalence of
by absolute frequencies and percentages for qualitative high stress across people suffering from a different number
variables. Independent t-student test and one-way analysis of FGIDs (0-4) was 14% to 48.9%, respectively (P < 0.001). The
of variance or Kruskal-Wallis test (when assumptions participants with high stress were more likely to report a lack
including normality or homogeneity of variance were not of social supports and more perceived intensity of stress (P
hold) were used to compare mean differences of quantitative < 0.001). Table 1 also showed the anxiety score in different
variables between two and multiple groups, respectively. levels of the basic characteristics of study participants. The
Distribution of study participants in terms of qualitative mean anxiety scores were statistically different in gender and
variables across different categories of other variables educational levels (P < 0.001). Similarly, significant differences
was compared using the Chi-square test. The associations were found among people who were in different smoking
between anxiety score and quantitative variables were tested levels and physical activity groups as well as number of
by Spearman rank correlations coefficient. Multivariate FGIDs in terms of anxiety scores (all are significant at P <
generalized linear mixed model was performed for joint 0.01). There were significant relationship between the social
modeling of anxiety score (continuous) and psychological support and perceived intensity of stress with anxiety scores
stress (dichotomous) as mixed dependent variables and (P < 0.001) but no significant correlations were detected
personality traits as independent variables using shared among age and BMI with anxiety score. Personality traits
random effect models. Adjusted odds ratio (OR) and (neuroticism, extraversion, openness, agreeableness and
regression coefficients (95% confidence intervals [CI]) for conscientiousness) were categorized based on their median
psychological stress and anxiety score are presented in scores. The frequencies of personality trait groups in different
5 different models. First, we adjusted for demographic levels of the basic characteristics of study participants are also
variables including age, sex, marital status, educational presented in Table 1. Individuals in the high-neuroticism and
levels. We further controlled for lifestyle variables including low extraversion scores were female (P < 0.001) and tended to
smoking, BMI, physical activity in the second model. have lower physical activity (P < 0.001) and education level
Additional adjustments were made for a number of FGIDs (P < 0.001), lower social support (P < 0.001), higher perceived
in the third model. Fourth adjusted model was further intensity of stress (P < 0.001) and were more likely to have
controlled for perceived intensity of stress. In the final more number of FGIDs (P < 0.001) as compared to those
model, a further adjustment was made for social support. in the low-neuroticism and high extraversion scores. The
In all models, the category of low stress of psychological comparisons of stress level and anxiety score in personality
stress was considered as the reference categories. P < 0.05 trait groups were provided in Table 2. Higher significant
were considered as statistically significant. psychological stress was found among those people who
were in the above median category of neuroticism than
RESULTS below median. In contrast, subjects in the high-stress
group were significantly more likely to be in the category
The average (SD) age of the 3180 was 35.91 (7.76) years. 60.5% of below median of extraversion, openness, agreeableness
of the sample were female. 61.4% of the study participants and conscientiousness score compared with subjects in the
had a college education. About 16% of subjects were current above median category. Furthermore, among participants
or past smokers. 46.5% participated in regular physical who were in the category of above median of neuroticism,
activity. About 45.6% of subjects suffer from overweight anxiety score were significantly more than others (5.42 ± 3.99
or obesity, and approximately 53% of the respondents vs. 1.76 ± 2.09, P < 0.001). As Table 2 shows, more participants
reported experiencing some FGIDs including GERD, FD, in the category of below median of extraversion, openness,
FC and IBS. Altogether 23.9% (n = 761) of participants based agreeableness and conscientiousness were also found to be
on the GHQ, had high psychological stress. Data on the suffering from possible anxiety than those who were in the
prevalence psychological stress in terms of gender, marital category of above median of studied traits (all, P < 0.001). Joint
status, education, ever smoke, physical activity and number modeling of anxiety score (continuous) and Psychological
of FGIDs are presented in Table 1. The percentage of women stress (dichotomous) as the response variables on the
with high-stress levels was significantly higher than the different categories of personality traits as the predictor

837 Journal of Research in Medical Sciences | September 2014 |

 Table 1: The comparison of anxiety score, psychological stress and categories of personality traits in different levels of demographic variables
Demographic Anxiety Psychological stress Neuroticism Extraversion Openness Agreeableness Conscientiousness
variables score
Low stress High stress <median ≥median <median ≥median <median ≥median <median ≥median <median ≥median
(%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%)

| September 2014 |
Sex
Male 2.93±3.29 1027 (81.8) 229 (18.2) 706 (56.2) 550 (43.8) 522 (41.6) 734 (58.4) 519 (41.3) 737 (58.7) 641 (51.0) 615 (49.0) 562 (44.7) 694 (55.3)
Female 4.05±3.85 1392 (72.3) 532 (27.7) 867 (45.1) 1057 (54.9) 1058 (55.0) 866 (45.0) 773 (40.2) 1151 (59.8) 834 (43.3) 1090 (56.7) 862 (44.8) 1062 (55.2)
P <0.001 <0.001 <0.001 <0.001 0.52 <0.001 0.97
Marital status
Married 3.63±3.72 1986 (76.4) 613 (23.6) 1284 (49.4) 1315 (50.6) 1285 (49.4) 1314 (50.6) 1094 (42.1) 1505 (57.9) 1205 (46.4) 1394 (53.6) 1182 (45.5) 1417 (54.5)
Single 3.54±3.49 433 (74.5) 148 (25.5) 289 (49.7) 292 (50.3) 295 (50.8) 286 (49.2) 198 (34.1) 383 (65.9) 270 (46.5) 311 (53.5) 242 (41.7) 339 (58.3)
P 0.59 0.33 0.88 0.56 <0.001 0.96 0.09
Education level
<12 years 4.63±4.34 244 (65.6) 128 (34.4) 130 (34.9) 242 (65.1) 218 (58.6) 154 (41.4) 238 (64.0) 134 (36.0) 211 (56.7) 161 (43.3) 193 (51.9) 179 (48.1)
12 3.95±3.98 648 (75.9) 206 (24.1) 398 (46.6) 456 (53.4) 416 (48.7) 438 (51.3) 375 (43.9) 479 (56.1) 412 (48.2) 442 (51.8) 369 (43.2) 485 (56.8)
>12 years 3.27±3.35 1527 (78.1) 427 (21.9) 1045 (53.5) 909 (46.5) 946 (48.4) 1008 (51.6) 679 (34.7) 1275 (65.3) 852 (43.6) 1102 (56.4) 862 (44.1) 1092 (55.9)
P <0.001 <0.001 <0.001 0.001 <0.001 <0.001 0.012
Ever smoke
Never 3.53±3.65 2044 (76.4) 630 (23.6) 1338 (50.04) 1336 (49.96) 1322 (49.4) 1352 (50.6) 1066 (39.9) 1608 (60.1) 1213 (45.4) 1461 (54.6) 1173 (43.9) 1501 (56.1)
Past and current 4.02±3.83 375 (74.1) 131 (25.9) 235 (46.4) 271 (53.6) 258 (51.0) 248 (49.0) 226 (44.7) 280 (55.3) 262 (51.8) 244 (48.2) 251 (49.6) 255 (50.4)
P 0.007 0.26 0.14 0.52 0.044 0.008 0.017
Physical activity
Inactive 3.89±3.78 1251 (73.5) 451 (26.5) 773 (45.4) 929 (54.6) 933 (54.8) 769 (45.2) 718 (42.2) 984 (57.8) 816 (47.9) 886 (52.1) 833 (48.9) 869 (51.1)
Active 3.28±3.54 1168 (79.0) 310 (21.0) 800 (54.1) 678 (45.9) 647 (43.8) 831 (56.2) 574 (38.8) 904 (61.2) 659 (44.6) 819 (55.4) 591 (40.0) 887 (60.0)
P <0.001 <0.001 <0.001 <0.001 0.055 0.058 <0.001
Number of FGIDs

Journal of Research in Medical Sciences

0 2.26±2.70 1286 (86.0) 209 (14.0) 918 (61.4) 577 (38.6) 621 (41.5) 874 (58.5) 590 (39.5) 905 (60.5) 630 (42.1) 865 (57.9) 584 (39.1) 911 (60.9)
1 3.89±3.59 647 (72.9) 240 (27.1) 405 (45.7) 482 (54.3) 464 (52.3) 423 (47.7) 357 (40.2) 530 (59.8) 421 (47.5) 466 (52.5) 413 (46.6) 474 (53.4)
2 5.42±4.05 322 (63.5) 185 (36.5) 169 (33.3) 338 (66.7) 309 (60.9) 198 (39.1) 223 (44.0) 284 (56.0) 263 (51.9) 244 (48.1) 270 (53.3) 237 (46.7)
3 6.52±4.49 141 (57.3) 105 (42.7) 70 (28.5) 176 (71.5) 155 (63.0) 91 (37.0) 101 (41.1) 145 (58.9) 139 (56.5) 107 (43.5) 136 (55.3) 110 (44.7)
4 6.73±3.66 23 (51.1) 22 (48.9) 11 (24.4) 34 (75.6) 31 (68.9) 14 (31.1) 21 (46.7) 24 (53.3) 22 (48.9) 23 (51.1) 21 (46.7) 24 (53.3)
P <0.001 <0.001 <0.001 <0.001 0.41 <0.001 <0.001
Feizi, et al.: The association of personality traits with anxiety and psychological stress

Age (years) −0.021 36.06±7.85 35.41±7.45 36.17±7.87 35.65±7.65 36.04±7.51 35.78±7.99 36.81±7.81 35.29±7.67 36.10±7.74 35.75±7.78 35.71±7.57 36.07±7.91
P 0.23 0.038 0.06 0.35 <0.001 0.20 0.19
Social support −0.341 8.26±3.37 5.65±3.81 8.77±3.14 6.53±3.78 6.42±3.776 8.84±3.09 7.08±3.68 8.02±3.58 6.79±3.77 8.37±3.38 6.82±3.77 8.31±3.41
P <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
Perceived 0.491 24.59±16.53 42.05±21.29 21.74±14.75 35.65±20.67 32.56±20.44 25.02±17.28 29.29±19.63 28.40±19.04 33.32±20.9 24.82±16.8 31.16±20.16 26.83±18.3
intensity of
stress
P <0.001 <0.001 <0.001 <0.001 0.20 <0.001 <0.001
BMI 0.0041 24.93±3.81 24.74±4.03 24.95±3.73 24.82±3.98 24.79±3.98 24.97±3.74 25.16±3.93 24.69±3.80 25.11±3.93 24.69±3.79 25.01±3.91 24.78±3.82
P 0.84 0.23 0.36 0.21 0.001 0.003 0.09
1

838
Correlation coefficient; BMI = Body mass index; FGIDs = Functional gastrointestinal disorders including; GERD = Gastro Esophageal acid Reflux Disease; FD = Functional Dyspepsia; FC = Functional Constipation; IBS = Irritable Bowel Syndrome
 Feizi, et al.: The association of personality traits with anxiety and psychological stress

variables in different models were given in Table 3. In all for correlation and co-morbidity between mixed outcomes.
fitted models, the category of below median of personality In crude models, we reached a joint significant positive
traits (in predictor variables) and low level of psychological association among stress level and anxiety score with high-
stress were defined as the reference category. Adding shared neuroticism score (OR: 9.21; 95% CI: 6.96-12.06 and β: 3.05;
random effect to joint modeling of anxiety score (continuous) 95% CI: 2.80-3.29). On the contrary, we found joint inverse
and Psychological stress (dichotomous) is a way to account associations between stress level and anxiety score with
high extraversion score (OR: 0.28; 95% CI: 0.22-0.36 and β:
Table 2: The comparison of psychological stress and −1.04; 95% CI: −1.29-−0.79). Likewise, there were inverse
anxiety score in categories of personality traits significant relationships between high-stress level and
Personality Psychological stress Anxiety P high conscientiousness (OR: 0.71; 95% CI: 0.56-0.91), but no
traits Low High P score significant association between high conscientiousness and
stress (%) stress (%)
anxiety scores. Furthermore, we resulted negative significant
Neuroticism
<Median 1483 (94.3) 90 (5.7) 1.76±2.09
relationship between anxiety score and high-agreeableness
<0.001 <0.001 score (β: −0.59; 95% CI: −0.83-−0.35). After adjusting for
≥Median 936 (58.2) 671 (41.8) 5.42±3.99
Extraversion a wide range of potential confounding variables such as
<Median 977 (61.8) 603 (38.2) 4.80±4.08 age, sex, marital status, education level, ever smoke, BMI,
<0.001 <0.001
≥Median 1442 (90.1) 158 (9.9) 2.43±2.79 physical activity, number of FIGDs, Perceived intensity of
Openness stress and social supports, the same finding was also found
<Median 938 (72.6) 354 (27.4) 3.89±3.83
<0.001 <0.001 in high-stress level and anxiety score with some personality
≥Median 1481 (78.4) 407 (21.6) 3.42±3.56
traits except for conscientiousness and anxiety score. In full
Agreeableness
<Median 993 (67.3) 482 (32.7) 4.62±3.97 adjusted model, there was the inverse significant association
<0.001 <0.001
≥Median 1426 (83.6) 279 (16.4) 2.73±3.17 between anxiety score and high-conscientiousness score
Conscientiousness (β: −0.23; 95% CI: −0.45-−0.02). More details on the relationship
<Median 940 (66.0) 484 (34.0)
<0.001
4.50±3.98
<0.001
between psychological stress and anxiety with personality
≥Median 1479 (84.2) 277 (15.8) 2.88±3.25 traits in different models can be found in Table 3.

Table 3: Table 3: Crude and adjusted odds ratio (OR) and regression coefficients (95% CI for ORs and coefficients)
resulted from joint modeling of anxiety score and psychological stress as dependent variables and five-factors
personality traits as independent variables
Dependent variables Independent variables
≥Median
Neuroticism2 Extraversion2 Openness2 Agreeableness2 Conscientiousness2
Crude
Psychological stress1a 9.21 (6.96, 12.06)* 0.28 (0.22, 0.36)* 1.08 (0.86,1.35) 0.90 (0.70, 1.13) 0.71 (0.56, 0.91)*
Anxiety scoreb 3.05 (2.80, 3.29)* −1.04 (−1.29, −0.79)* 0.19 (−0.03, 0.42) −0.59 (−0.83, −0.35)* −0.21 (−0.45, 0.04)
Model 1
Psychological stress1a 8.67 (6.62, 11.36)* 0.30 (0.23, 0.38)* 1.09 (0.88,1.39) 0.86 (0.68, 1.09) 0.70 (0.55, 0.89)*
Anxiety scoreb 2.88 (2.64, 3.12)* −0.95 (−1.19, −0.69)* 0.29 (0.06, 0.52)* −0.68 (−0.92, −0.44)* −0.24 (−0.48, 0.01)
Model 2
Psychological stress1a 8.67 (6.55, 11.36)* 0.30 (0.23, 0.38)* 1.09 (0.88,1.38) 0.86 (0.68, 1.09) 0.70 (0.55, 0.89)*
Anxiety scoreb 2.88 (2.63, 3.12)* −0.95 (−1.20, −0.71)* 0.29 (0.06, 0.52)* −0.67 (−0.91, −0.42)* −0.21 (−0.46, 0.03)
Model 3
Psychological stress1a 7.77 (5.87, 10.28)* 0.30 (0.24, 0.39)* 1.08 (0.86, 1.36) 0.86 (0.68, 1.09) 0.71 (0.56, 0.91)*
Anxiety scoreb 2.50 (2.26, 2.73)* −0.82 (−1.06, −0.58)* 0.24 (0.02, 0.45)* −0.65 (−0.88, −0.42)* −0.15 (−0.39, 0.08)
Model 4
Psychological stress1a 5.47 (4.10, 7.32)* 0.31 (0.24, 0.41)* 0.98 (0.77, 1.25) 1.02 (0.79, 1.31) 0.64 (0.50,0.82)*
Anxiety scoreb 1.81 (1.58, 2.03)* −0.67 (−0.89, −0.45)* 0.09 (−0.11, 0.29) −0.36 (−0.57, −0.15)* −0.27 (−0.48, −0.05)*
Model 5
Psychological stress1a 5.10 (3.82, 6.82)* 0.36 (0.28, 0.47)* 1.02 (0.8, 1.31) 1.05 (0.83, 1.36) 0.65 (0.51, 0.84)*
Anxiety scoreb 1.73 (1.50, 1.95)* −0.54 (−0.76,−0.32)* 0.12 (−0.08, 0.32) −0.32 (−0.53,−0.11)* −0.23 (−0.45,−0.02)*
*P < 0.05; 1Low level of psychological stress were defined as reference category; 2Category of below median of personality traits were considered as reference category; aData
were expressed as OR (95% CI); bData were expressed as regression coefficients (95% CI). Model 1: Adjusted for demographic variables (age, sex, marital status, education level);
Model 2: Adjusted for demographic variables and lifestyle (ever smoke, BMI, physical activity); Model 3: Adjusted for demographic variables, lifestyle and number of FGIDs; Model 4:
Adjusted for demographic variables, lifestyle, number of FGIDs and perceived intensity of stress; Model 5: Adjusted for demographic variables, lifestyle, number of FGIDs, perceived
intensity of stress and social supports; OR = Odds ratio; CI = Confidence interval; FGIDs = Functional gastrointestinal disorders including; GERD = Gastro Esophageal acid Reflux
Disease; FD = Functional Dyspepsia; FC = Functional Constipation; IBS = Irritable Bowel Syndrome; BMI = Body mass index

839 Journal of Research in Medical Sciences | September 2014 |

 Feizi, et al.: The association of personality traits with anxiety and psychological stress

DISCUSSION Bienvenu et al. multivariate analysis of variance was used

to compare those with particular disorders to those with
In this cross-sectional population-based study, association none of the five disorders of interest (anxiety (including
between some personality traits and psychological simple phobia, social phobia, agoraphobia, and panic
problems (anxiety and psychological stress) was largely disorder) and major depressive disorders). All five-factors
supported by the data in Iranian adult population. Adding were thus assessed simultaneously in single models. These
shared random effect to the joint model of anxiety scores results indicated that neuroticism, extraversion, and facets
(continuous) and Psychological stress (dichotomous) is of agreeableness and conscientiousness are important
one of the appropriate approaches to accounting for co- constructs in understanding relationships between
morbidity and correlation between mixed outcomes. In personality traits and anxiety and depressive conditions
fact, high scores of neuroticism compared with low scores, in the general population. Neuroticism is broadly
after controlling for all considered confounders such as associated with social phobia, agoraphobia, panic disorder,
age, sex, marital status, education level, ever smoke, BMI, and major depression. Introversion is only broadly
physical activity, number of FGIDs, perceived intensity of associated with social phobia and agoraphobia. Lower-
stress and social supports “(full adjusted model)”, order dimensions of agreeableness appear relevant to
increased the chance of high psychological stress. Likewise, phobias, and those of conscientiousness appear relevant
high scores of neuroticism compared with low scores had to phobic, panic and major depressive disorders.[14] These
an additive impact on mean of anxiety score after control results are concordant with our results demonstrating
for a wide range of potential confounding variables. The associations between Neuroticism, extraversion,
association between neuroticism and both psychological agreeableness and conscientiousness with anxiety. In the
stress and anxiety were of course as expected, because study of Kotov et al. examination of the trait — symptom
there is ample evidence in the literature indicating that links using hierarchical multiple regression analyses
people who had high levels of anxiety and stress are demonstrated that neuroticism and negative emotionality
characterized by high neuroticism score. Also, neuroticism had notable associations with all anxiety symptom
has been regarded as a predisposition to develop all kinds disorders and showed an especially strong link to worry.
of psychopathology disorders.[7,14,19] Further, in keeping Extraversion and positive emotionality accounted for
with previous studies,[7,14,17,19] results indicated that the substantial additional variance in social anxiety. In sum,
high scores of extraversion and conscientiousness the results of this study confirmed neuroticism as a general
compared with low scores, after controlling for all factor with all anxiety disorders. However, extraversion
confounding variables in the fully adjusted model, was and positive emotionality have significant relations to
associated with 64% and 35% lower chance of high some syndromes but emerged as a unique factor linked
psychological stress. Furthermore, it is expected that the only to social anxiety. This study was based entirely on
high scores of extraversion, agreeableness and the responses of college students, who generally report
conscientiousness caused to reduce the mean of anxiety relatively low levels of psychopathology. However, other
score. In the study of Newbury-Birch and Kamali the personality traits were not considered in their study.[17]
significant inverse relationships were seen between People respond differently to stressful situations, and it
personality characteristics of neuroticism and both stress appears that those who suffer least from mental problems
and anxiety without adjustment for established do so by adopting appropriate coping strategies. The way
confounding variables amongst 109 juniors doctor in the individuals cope with stressful situations may also be
north east of England. The study further revealed that related to their personality characteristics.[7] In the other
women who had higher neuroticism and lower extraversion words, people with different personality traits show
scores had higher stress and anxiety scores compared with different coping methods and different levels of
the rest of the group. [7] In another study, which was vulnerability in experiencing a stressful situation.[42] This
performed among 731 community subjects demonstrated study further established that some participants might be
that all of the lifetime disorders of interest, including more vulnerable to stress and anxiety as a result of their
anxiety and depression disorders were associated with personality characteristics. Furthermore, Zautra et al. used
high neuroticism and some anxiety disorders were the developed multilevel modeling methodology that can
associated with low extraversion. In this study, description measure responses within individuals, across time, and
of lower-order personality traits, particularly in anxiety still test for traditional between-individual differences.
disorders were further showed. They mentioned that They used the dimensions of neuroticism and extraversion
lower-order dimensions (facets) of agreeableness and for the prediction of between-individual differences in
conscientiousness were also inversely associated with their study. The study revealed that neuroticism predicted
certain anxiety disorders.[41] In this regard, similar results lower positive emotionality, higher negative affect and
were observed in the current study. In the study of more negative and stressful events. They further found

| September 2014 | Journal of Research in Medical Sciences 840

 Feizi, et al.: The association of personality traits with anxiety and psychological stress

neuroticism to aggravate the negative impact of negative relationships between personality traits and mental
events. However, Extraversion, on the other hand, problems with cross-sectional studies. Also, the current
predicted higher positive effect and more positive results are based entirely on the participants’ self-ratings,
events.[43] In addition, negative affectivity itself is related and it obviously is important to consider other types of
to negative health perceptions in people who were high data as well. In this regard, it would be particularly
in neuroticism. Individuals scoring high on some aspects informative to assess each of the underlying results in this
of personality, including neuroticism may have a tendency study using multiple methods (e.g., self-ratings, clinicians’
to report more symptoms of medical and mental problems, ratings, and peer-ratings). This multi-method design
negatively perceived health status, health worries, would permit powerful analyses of personality-
frequency of visits to the general physician and poorer psychopathology relations. Furthermore, we adopted a
mental health. Despite their greater health worries, simple approach to handling missing data (complete-case),
neurotic people have also been found to show less sensible as our data were fairly complete. However, future studies
health behaviors.[44,45] Neuroticism is the general trait that may benefit from more sophisticated methods, such as
is common to all mental disorders and would be broadly multiple imputations. Further studies are required to
associated with the development of mental disorders.[17] confirm our findings.
Extraversion, on the other hand was found to predispose
to the experience of most pleasurable events and more CONCLUSION
positive effects and emotionality. People with a high score
on extraversion have been found to report fewer Investigation of relations between personality traits
psychological and physical symptoms and was associated and high-prevalence mental problems can provide
with a better-perceived health status, through its influence important information on the dimensional measures of
on well-being and positive affect which lessens health psychopathology and screen for psychological factors in
worries. Conscientiousness and agreeableness are the primary care settings. Such researches can provide a
associated with positive perceptions.[15,19,44,45] In general somewhat clear perspective on the relationship between
practice settings, it is likely that understanding of personality traits and psychopathology and finally will
personality aids practitioners in assessing and dealing enhance our knowledge about psychological problems
with people they know reasonably well. However, in a and lead to improvement in mental and physical
hospital setting, there is often little opportunity for getting health. According to likely mechanism of genetic and
to know the personality of a patient in a busy clinic or environmental factors on the relationships between
ward. Inclusion of formal information on personality traits personality traits and psychological disorders,[46,47] it
could be helpful. It is worthwhile that personality traits is suggested to perform longitudinal studies focusing
on both genetic and environmental factors in Iranian
be taken into consideration when offering support and
population.
counseling. Most previous research focused on anxiety
and stress as single risk indicators, and also characteristics
of personality traits as single predictors of mental
ACKNOWLEDGMENTS
problems. These negative emotions and personality traits
The present paper was a M. S. thesis in biostatistics at School of
were investigated simultaneously in the present study. To Health, Isfahan University of Medical Sciences; Research Project
the best of our knowledge, there has not been any report Number: 392371.
regarding the influence of personality traits on both stress
and anxiety the shared random effects model. Although AUTHOR’S CONTRIBUTION
the proposed framework obviously needs further
explication, it appears to be a useful guide for personality — AF contributed in the conception and design of the work,
psychopathology research. The strengths of this study manuscript preparation, drafting and revising the draft,
include the use of a wide range of likely confounding conducting the study, approval of the final version of the
variables, including sex, age, marital status, education manuscript, and agreed for all aspects of the work. AHK
level, BMI, Perceived intensity of stress, social support, contributed in the conception and design of the work,
ever smoke, physical activity and number of FGIDs, the drafting and revising the draft, conducting the study,
reasonably comprehensive yet manageable measure of approval of the final version of the manuscript, and agreed
five-factor personality traits, NEO questionnaire, large and for all aspects of the work. FN contributed in the manuscript
representative sample, comprehensive statistical method preparation, analysis, interpretation of data, drafting and
with a focus on correlation between mixed outcomes and revising the draft, conducting the study, approval of the
considering five personality traits simultaneously in the final version of the manuscript, and agreed for all aspects
all models. However, we should consider some limitation of the work. HR contributed in the conception and design
in interpretation of the results. It is difficult to assess causal of the work, drafting and revising the draft, conducting the

841 Journal of Research in Medical Sciences | September 2014 |

 Feizi, et al.: The association of personality traits with anxiety and psychological stress

study, approval of the final version of the manuscript, and 21. Dube SR, Caraballo RS, Dhingra SS, Pearson WS, McClave AK,
agreed for all aspects of the work. PA contributed in the Strine TW, et al. The relationship between smoking status and
serious psychological distress: Findings from the 2007 Behavioral
conception and design of the work, drafting and revising
Risk Factor Surveillance System. Int J Public Health 2009;54 Suppl
the draft, conducting the study, approval of the final version 1:68-74.
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sensitivity to stress: A unifying theory. Clin Psychol Rev 2001;21:
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Source of Support: Nil, Conflict of Interest: None declared.
approaches to emotions and stress in everyday life: Bolger and

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