The Contribution of Previous Contact and Personality Traits to Severe Mental Illness Stigma

The Associations Among Observers' Openness to Experience and Agreeableness With Social Distance: The Moderating Role of Disability Type

ABSTRACT

Despite abundant literature on personality and stigma, the role of disability type in this relationship has remained unaddressed. In the current study, we examined whether the relationship between observers' openness to experience and agreeableness on the one hand, and social distance on the other, was moderated by the target person's type of disability (psychiatric vs. physical). One hundred thirty-nine participants were randomly assigned to complete a social distance questionnaire referring to a vignette of a person in three conditions (physical disability, psychiatric disability, and control). A main effect of openness on social distance was found. Additionally, we found an interaction effect of agreeableness and the type of disability. Namely, the relationship between agreeableness and social distance was significant only in the physical disability condition but not in the other two conditions. To conclude, the current study emphasizes the role of personality traits in social distance toward individuals with disabilities.

Mental health treatment stigma, maladaptive personality trait domains, and treatment-seeking attitudes and behaviors

OBJECTIVES

A barrier to seeking mental health care is treatment stigma, a form of stigma associated with seeking/receiving mental health treatment. Prior research has also demonstrated relationships between five-factor model personality traits and treatment-seeking attitudes. However, findings in this area are mixed and research has tended not to include assessments of maladaptive personality traits outlined in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition Section III: Emerging Measures and Models. The present study sought to examine relationships between maladaptive personality traits, treatment stigma, and treatment-seeking attitudes and behavior in an adult sample.

METHODS

Participants (N = 500) completed a series of questionnaires assessing current and past mental health treatment-seeking behaviors, treatment stigma, attitudes toward treatment seeking, and maldaptive personality traits.

RESULTS

Results revealed all five maladaptive personality traits were positively associated with increased treatment stigma, and in models controlling for the shared variance across maladaptive personality traits, negative affect, antagonism, psychoticism, and stigma exhibited unique associations with one's perceived value and need of mental health treatment, whereas negative affect, detachment, and stigma were uniquely associated with openness to seeking mental health treatment for emotional problems. While the five maladaptive personality traits were associated with a history of treatment-seeking behaviors at the bivariate level and after controlling for stigma, only negative affect was uniquely associated with treatment-seeking behaviors in a model including all five personality trait domains. Exploratory moderation analyses revealed associations between stigma and openness to seeking treatment varied as a function of maladaptive personality traits.

CONCLUSIONS

This study extends prior research on the role of personality traits in understanding treatment-seeking attitudes and behaviors and may have clinical implications for the use of maladaptive personality trait screeners in practice.

Prejudice and determinants regarding tuberculosis patients among medical students in Dalian, Northeast China: a cross-sectional study

Background

Health workers play a central role in global tuberculosis (TB) elimination efforts. If medical students have prejudiced attitudes toward TB patients, this may make it difficult for them to provide effective health care to TB patients in their future roles as health workers. There is currently no research on prejudice toward TB patients among medical students in China. This study aimed to explore the current status of medical students' prejudice against patients with TB and its associated predictors.

Methods

We conducted a cross-sectional questionnaire survey among medical students at a medical university in Dalian, Liaoning Province, Northeast China. Multiple logistic regression analysis was employed to determine the predictive factors of medical students' prejudice against patients with TB.

Results

More than half (57.23%) of the medical students held prejudices against individuals with TB. Multivariate logistic regression analysis revealed that not receiving TB health education (OR: 2.12, 95% CI: 1.35-3.32), not knowing a person with TB (OR: 2.52, 95% CI: 1.39-4.56), and fear of TB/TB patients (OR: 6.79, 95% CI: 4.36-10.56) were identified as risk factors for medical students' prejudice against TB patients. Conversely, residing in rural areas (OR: 0.60, 95% CI: 0.38-0.95), agreeableness (OR: 0.82, 95% CI: 0.73-0.92) and emotional stability (OR: 0.90, 95% CI: 0.81-1.00) in the Big Five personality traits, and a better understanding of TB knowledge (OR: 0.58, 95% CI: 0.38-0.89) were identified as protective factors.

Conclusion

In China, a considerable number of medical students still exhibit prejudice against patients with TB. Targeted interventions, such as incorporating TB health education into the core curriculum of medical students, and enhance their agreeableness and emotional stability, are still needed. Furthermore, greater focus should be placed on medical students from urban backgrounds or those who harbor fear or do not know a person with TB.

A Comparison of Social Exclusion Towards People with Depression or Chronic Back Pain

Objectives

Research comparing mental and physical health stigma is scarce. The aim of this study was to compare social exclusion towards hypothetical males and females with depression or chronic back pain. Furthermore, the study investigated whether social exclusion is associated with participant's empathy and personality traits, while controlling for their sex, age and personal exposure to mental/physical chronic health conditions.

Design

This study employed a cross-sectional questionnaire design.

Methods

Participants (N = 253) completed an online vignette-based questionnaire and were randomly allocated to either a depression or chronic back pain study condition. Measures of social exclusion through respondents' willingness to interact with hypothetical individuals, empathy and the Big Five personality traits were completed.

Results

Willingness to interact scores did not significantly differ depending on the diagnosis or sex of the hypothetical person in the vignette. For depression, higher levels of conscientiousness significantly predicted less willingness to interact. Whilst being a female participant and having higher empathy significantly predicted greater willingness to interact. For chronic back pain, higher empathy significantly predicted greater willingness to interact, with no significant predictors found from the Big Five personality traits.

Conclusion

Findings indicate that females and males with depression or chronic back pain face similar levels of social exclusion, with empathy being a core variable driving social exclusion behaviours. These findings enhance our understanding of potential variables driving social exclusion, in-turn informing campaign development to reduce public stigma towards depression and chronic back pain.

Depression literacy and misconceptions scale (DepSter): a new two-factorial tool for measuring beliefs about depression

BACKGROUND

Depression literacy has received extensive attention within mental health research. It has been studied by different social groups and professions in Western and non-Western cultures. The importance of this topic stems from the fact that depression literacy is strongly related to attitudes toward people who are diagnosed with depression, the tendency to stigmatize this mental disorder, and to the propensity to undertake help-seeking behaviors. Therefore, understanding and promoting depression literacy is crucial in contemporary mental health prevention and promotion. We propose a new two-factorial tool measuring beliefs about depression. This 14-item self-report measure captures how people vary across two dimensions of beliefs about depression-depression literacy and misconceptions about depression.

METHODS

In ten studies with a total sample of over 4,600 participants from three countries, we demonstrated the two-factorial structure of the Depression Literacy and Misconceptions Scale (DepSter) in Polish (Studies 1 and 2), American (Study 4), and British (Study 5) samples. We showed measurement equivalence for the Polish and English versions of the scale (Study 3). Furthermore, we tested the discriminant meaning of the two dimensions of beliefs about depression analyzing its association with health literacy, mental health literacy, and prejudice toward people with mental illness (Study 4), depression literacy and depression stigma (Study 5), empathetic concerns (Study 7), social dominance orientation (Study 8), and the Big Five personality traits (Study 9). We also investigated whether individuals with formal education in psychology and direct or indirect experience with depression demonstrate a higher level of depression literacy and a lower level of misconceptions about depression (Study 6). Our measure showed high stability for two dimensions of beliefs about depression (Study 10), in both its Polish and English versions, with the measurement conducted after three weeks and three months.

DISCUSSION

We conclude that the proposed approach to beliefs about depression capturing both depression literacy and misconceptions about depression measured with the DepSter scale can easily be applied in clinical and social settings, especially in studies concerning the perception of those diagnosed with depression.

Are the “Big 5” Personality Traits Associated With Substance Use Self-Stigma?

Self-stigma among individuals with substance use problems is notably high, but not all individuals with substance use problems experience elevated self-stigma. Unfortunately, there is limited research to account for such variation. A few studies have examined the association between personality traits from the five-factor model (FFM; “Big 5”) and self-stigma among those with mental illness, but no research exists among individuals with substance use disorders. Based on data from 125 individuals residing in a substance use treatment unit, the FFM personality traits collectively account for 33% to 56% of the variance across four components of self-stigma. More specifically, individuals with high neuroticism, low conscientiousness, and/or low extraversion experience greater self-stigma. The identification of at-risk individuals, via personality traits, could allow for development of targeted interventions to address self-stigma, and ultimately improve treatment retention and outcomes.

Attitudes toward mental illness among medical students and impact of temperament

BACKGROUND

Mental health-related stigma is a serious problem that has undesirable consequences for individuals with mental disorders including physical health disparities, increasing mortality, and social dysfunction. Besides, these individuals frequently report feeling 'devalued, dismissed, and dehumanized' when encountering health professionals who are also perpetrators of stigmatizing attitudes and discriminatory behaviors.

AIMS

The present study concentrates on attitudes, and behavioral responses of medical students and junior doctors toward individuals with a mental illness and explores factors associated with stigma including temperament.

METHODS

A cross-sectional study was conducted among medical students and junior doctors from medical schools of universities in Tunisia. All participants were invited to complete a brief anonymous electronic survey administered on the google forms online platform. Data were collected using self-administered questionnaires, Stigma Measurement, Mental Illness: Clinicians' Attitudes (MICA), Assessment of Affective Temperament, TEMPS-A scale.

RESULTS

A total of 1,028 medical students and junior doctors were recruited. The completion of a psychiatry clerkship for medical students didn't improve significantly the level of stigma toward people with a mental illness. Students in the fourth year had significantly the lowest MICA scores comparing to other students. Psychiatrists had significantly lower scores of explicit stigma attitudes than the other groups (Mean score = 0.42). As for other specialties, surgical residents had more stigmatizing attitudes than those who had medical specialties. 70% of participants believed that people with a mental illness are more dangerous than the other patients. Hyperthymic temperament was significantly associated with decreased stigma attitudes toward patients with mental illness.

CONCLUSION

A combination of medical school experiences of psychiatry's theoretical learning and clerkship and wider societal beliefs are important factors that shape students. Awareness of this will enable educators to develop locally relevant anti-stigma teaching resources throughout the psychiatry curriculum to improve students' attitudes toward mental illnesses.

Personality, self-esteem, familiarity, and mental health stigmatization: a cross-sectional vignette-based study

There has been little research exploring the relationship between personality traits, self-esteem, and stigmatizing attitudes toward those with mental disorders. Furthermore, the mechanisms through which the beholder's personality influence mental illness stigma have not been tested. The aim of this study is to examine the relationship between Big Five personality traits, self-esteem, familiarity, being a healthcare professional, and stigmatization. Moreover, this study aims to explore the mediating effect of perceived dangerousness on the relationship between personality traits and desire for social distance. We conducted a vignette-based representative population survey (N = 2207) in the canton of Basel-Stadt, Switzerland. Multiple regression analyses were employed to examine the associations between personality traits, self-esteem, familiarity, and being a healthcare professional with the desire for social distance and perceived dangerousness. The mediation analyses were performed using the PROCESS macro by Hayes. Analyses showed associations between personality traits and stigmatization towards mental illness. Those who scored higher on openness to experience (β = - 0.13, p < 0.001), (β = - 0.14, p < 0.001), and those who scored higher on agreeableness (β = - 0.15, p < 0.001), (β = - 0.12, p < 0.001) showed a lower desire for social distance and lower perceived dangerousness, respectively. Neuroticism (β = - 0.06, p = 0.012) was inversely associated with perceived dangerousness. Additionally, high self-esteem was associated with increased stigmatization. Personal contact or familiarity with people having mental disorders was associated with decreased stigmatization. Contrarily, healthcare professionals showed higher perceived dangerousness (β = 0.04, p = 0.040). Finally, perceived dangerousness partially mediated the association between openness to experience (indirect effect = -  .57, 95% CI [- .71, - 0.43]) as well as agreeableness (indirect effect = - 0.57, 95% CI [- 0.74, - 0.39]) and desire for social distance. Although the explained variance in all analyses is < 10%, the current findings highlight the role of personality traits and self-esteem in areas of stigma. Therefore, future stigma research and anti-stigma campaigns should take individual differences into consideration. Moreover, the current study suggests that perceived dangerousness mediates the relationship between personality traits and desire for social distance. Further studies are needed to explore the underlying mechanisms of such relationship. Finally, our results once more underline the necessity of increasing familiarity with mentally ill people and of improving the attitude of healthcare professionals towards persons with mental disorders.

Effects of Integrated Moral Reasoning Development Intervention for Management of Violence in Schizophrenia: A Randomized Controlled Trial

Moral cognition is an important and multidimensional, but often overlooked, determinant of violence. Very few interventions have systematically examined the role of moral reasoning, anger management and problem-solving together in violence. A randomized controlled trial was conducted to comprehensively evaluate the sustained effects of an integrated Moral Reasoning Development Intervention (MRDI) in the management of repetitive violence in schizophrenia. This study placed special emphasis on essential components related to moral reasoning and violence in patients with schizophrenia. Evaluations, including measures of violence, moral reasoning, ethical valuation and judgement, decision-making, conflict management style, and personality traits, were performed at baseline, end of intervention, and 1-month follow-up after intervention. We found that MRDI was superior to treatment-as-usual, in improving moral reasoning and related variables and violence outcomes (p < 0.05). In comparison with the treatment-as-usual group (n = 22), patients in the MRDI group (n = 21) showed improved levels of moral reasoning, with decreased levels of violent behaviors. The MRDI participants also experienced significantly greater improvements or changes (p < 0.05) in their ethical valuation and judgement, decision-making style and preferences, and conflict management style. Our findings provide important implications for risk assessment and violence management and prevention.

Hide and seek – the role of personality, sense of coherence and experiential information in hidden information needs

Purpose

The aim of this study is to assess the impact of personality traits and sense of coherence (SOC) on concealing information needs out of shame. The study also investigates the link between concealed information needs and the use of experiential information for psychological wellbeing.

Design/methodology/approach

A Partial Least Square ‐ Structural Equation Modelling (PLS-SEM) approach is used to assess and analyse the proposed conceptual model, which is based on the responses of 412 upper secondary school students.

Findings

The findings reveal that personality traits not only have direct significant effects on concealing information needs but that their effects are also mediated by SOC. The positive relationship between concealed information needs and the use of experiential information is confirmed in the study.

Originality/value

This study is the first to show that personality and SOC influence concealing information needs. Two pathways are found. Firstly, negative emotionality and a low SOC lead to a heightened sense of shame. Secondly, introversion induces a more guarded behaviour. The study, moreover, quantitatively demonstrates a link between concealed information needs and the use of experiential information for psychological wellbeing.

Stigma toward people with COVID-19 among the Lebanese population: a cross-sectional study of correlates and mediating effects

INTRODUCTION

Stigma develops during outbreaks such as the COVID-19 pandemic due to the human fear that arises from the anxiety about a disease of an unknown etiology, with the associated detrimental consequences on both the individual and society. This study was conducted to assess if knowledge about COVID-19, attitude, practice and behavior regarding preventive measures against COVID-19, fear, and anxiety towards COVID-19 will affect the level of stigma and evaluate the mediating effect of fear, anxiety, and diagnosis of COVID-19 on stigma.

METHODS

A cross-sectional online survey conducted between December 20, 2020, and January 05, 2021, enrolled 405 participants recruited from the Lebanese population. Two scales were created and adapted to the Lebanese context to measure the current stigma (stigma discrimination scale, self-stigma scale) toward COVID-19.

RESULTS

More than half of the sample had moderate to severe stigma discrimination (62%) and self-stigma (65.9%). The multivariable analysis showed that higher fear of COVID-19 scale (Beta = .143) was significantly associated with a higher stigma discrimination scale. Whereas, higher knowledge score (Beta =  -.153) was significantly associated with a lower stigma discrimination scale. Fear of COVID-19, anxiety from COVID-19, being diagnosed with COVID-19, and having a family member with COVID-19 partially mediated the association between knowledge and stigma discrimination scale. No mediation effect of fear and anxiety scale was found between the knowledge and self-stigma score.

CONCLUSION

Our main findings indicate that a considerable proportion of the Lebanese population has stigma discrimination behaviors toward COVID-19 patients and that those who were infected with the virus experienced COVID-19-related stigmatization.

The Relationships Between Personality Traits and Public Stigma Attached to Families Bereaved Due To Suicide

Suicide is a serious global public-health issue that is perceived as the most stigmatizing of sudden losses. Most studies on this topic have examined how bereaved families perceive public stigma, paying less attention to the actual stigma experienced by those not directly bereaved. Therefore, this study examined the association between personality traits and the public stigma attached to families that have lost a member to suicide. Three hundred and eighty (N = 380) Israeli participants completed demographic, Big 5, and stigma questionnaires. The study findings demonstrate that neuroticism and openness to experience are associated with higher levels of public stigma, while conscientiousness is associated with lower levels of public stigma. In addition, Arab participants reported higher levels of public stigma than Jewish participants. These findings make an important contribution to our understanding of the relationship between personality traits and the public stigma attached to families that have lost a member to suicide.

Predictors of stigma in a sample of mental health professionals: Network and moderator analysis on gender, years of experience, personality traits, and levels of burnout

BACKGROUND

Stigma is one of the most important barriers to help-seeking and to personal recovery for people suffering from mental disorders. Stigmatizing attitudes are present among mental health professionals with negative effects on the quality of health care.

METHODS

Network and moderator analysis were used to identify what path determines stigma, considering demographic and professional variables, personality traits, and burnout dimensions in a sample of mental health professionals (n = 318) from six Community Mental Health Services. The survey included the Attribution Questionnaire-9, the Maslach Burnout Inventory, and the Ten-Item Personality Inventory.

RESULTS

The personality trait of openness to new experiences resulted to determine lower levels of stigma. Burnout (personal accomplishment) interacted with emotional stability in predicting stigma, and specifically, for subjects with lower emotional stability lower levels of personal accomplishment were associated with higher levels of stigma.

CONCLUSIONS

Some personality traits may be accompanied by better empathic and communication skills, and may have a protective role against stigma. Moreover, burnout can increase stigma, in particular in subjects with specific personality traits. Assessing personality and burnout levels could help in identifying mental health professionals at higher risk of developing stigma. Future studies should determine whether targeted interventions in mental health professionals at risk of developing stigma may be effective in stigma prevention.

How Are Personal Values Linked to Help-Seeking Stigma?

The extent to which individuals prioritize different personal values may be conceptually linked to the perceptions of societal stigma associated with seeking psychological help (public stigma), as well as the extent to which they apply that stigma to themselves (self-stigma). We examined how personal values predicted public stigma and self-stigma of seeking psychological help. Undergraduates ( N = 342) from two universities, one historically Black college/university and one predominantly White institution, completed questionnaires assessing personal values and public stigma and self-stigma of seeking psychological help. Self-transcendence values predicted lower self-stigma directly and indirectly via public stigma. Though there were no structural differences between the modeled relationships of values, public stigma, and self-stigma between Black/African American and White/European American undergraduates, the groups differed in their prioritization of self-transcendence, openness to change, and conservation values. Results suggest that understanding how individuals prioritize certain values over others may help explain group-differences in help-seeking stigmas.

Factors underlying cross-cultural differences in stigma toward autism among college students in Lebanon and the United States

Although stigma negatively impacts autistic people globally, the degree of stigma varies across cultures. Prior research suggests that stigma may be higher in cultures with more collectivistic orientations. This study aimed to identify cultural values and other individual differences that contribute to cross-cultural differences in autism stigma (assessed with a social distance scale) between college students in Lebanon (n = 556) and those in the United States (n = 520). Replicating prior work, stigma was lower in women than men and in the United States relative to Lebanon. Heightened autism knowledge, quality of contact with autistic people, openness to experience, and reduced acceptance of inequality predicted lower stigma. Collectivism was not associated with heightened stigma. Findings highlight the need to address structural inequalities, combat harmful misconceptions, and foster positive contact to combat stigma.

Gender, Personality Traits and Experience With Psychiatric Patients as Predictors of Stigma in Italian Psychology Students

A sample of undergraduate Psychology students (n = 1005), prevalently females (82.4%), mean age 20.5 (sd 2.5), was examined regarding their attitudes toward people suffering from mental illness. The survey instrument included a brief form for demographic variables, the Attribution Questionnaire-9 (AQ-9), the Ten Items Personality Inventory (TIPI), and two questions exploring attitudes toward open-door and restraint-free policies in Psychiatry. Higher levels of stigmatizing attitudes were found in males (Pity, Blame, Help, and Avoidance) and in those (76.5%) who had never had any experience with psychiatric patients (Danger, Fear, Blame, Segregation, Help, Avoidance and Coercion). A similar trend was also found in those who don't share the policy of no seclusion/restraint, while subjects who are favorable to open-door policies reported higher Coercion scores. No correlations were found between dimensions of stigma and personality traits. A machine learning approach was then used to explore the role of demographic, academic and personality variables as predictors of stigmatizing attitudes. Agreeableness and Extraversion emerged as the most relevant predictors for blaming attitudes, while Emotional Stability and Openness appeared to be the most effective contributors to Anger. Our results confirmed that a training experience in Psychiatry might successfully reduce stigma in Psychology students. Further research, with increased generalizability of samples and more reliable instruments, should address the role of personality traits and gender on attitudes toward people suffering from mental illness.

Direct and moderating effects of personality on stigma towards mental illness

BACKGROUND

While many studies have explored the concept and correlates of stigma towards individuals with mental illness, few have investigated the role of personality in this process. In the current study, we firstly examined the relationship between personality and stigma towards mental illness; and then explored the moderating effects of personality traits on the relationship between contact experience/s and stigma.

METHODS

Participants were recruited from public medical (N = 502) and nursing schools (N = 500) from April to September 2016 in Singapore for this cross-sectional survey, and they were randomly assigned to a vignette describing one of the following mental disorders: major depressive disorder, obsessive compulsive disorder, alcohol abuse, schizophrenia, and dementia. Stigma was measured by the 'Personal and Perceived scales of the Depression Stigma Scale' and the 'Social Distance Scale'. These scales together had a 3-factor structure based on a previous national study in Singapore, namely 'weak-not-sick', 'dangerous/unpredictable' and 'social distance'. Personality was measured by the 20-item short form of the International Personality Item Pool-five factor model measure.

RESULTS

Regression suggested agreeableness and openness to experience were negatively associated with all three domains of stigma. 'Weak-not-sick' and extraversion were positively associated; and 'social distance' was positively associated with higher scores on conscientiousness and neuroticism. Both close- and non-close contact were associated with more positive attitudes towards mental illness among the participants. Openness to experience moderated the relationships of close contact experience with 'weak-not-sick' and 'dangerous/unpredictable', but in different directions. The association between close contact and 'social distance' were moderated by agreeableness.

CONCLUSIONS

Unlike non-close contact experience, close contact with people with mental illness worked differently on stigma for individuals with different personality traits. Future studies are needed to further explore the underlying mechanisms for such differences.

Influencing factors of attitudes toward seeking professional help for mental illness among Korean adults

OBJECTIVES

Identifying predictors of psychological help-seeking attitudes is essential to improve access to needed mental health services. We investigated factors - particularly Big Five personality traits - that affect attitudes toward seeking professional psychological help for mental illness among Korean adults.

METHODS

A total of 654 participants aged 15-54 years were recruited through an online panel survey. Help-seeking attitudes for mental illness were measured by the Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPH), and personality traits were measured by the Big Five Personality Inventory-10.

RESULTS

Multivariate analyses showed that female gender, history of psychiatric diagnosis, agreeableness and openness to experience were significantly associated with positive attitudes toward seeking professional psychological help for mental illness.

CONCLUSIONS

These findings suggest that specific personality traits should be considered when developing strategies to promote positive attitudes toward seeking professional psychological help. Further research using a representative community sample is needed to generalize our findings.

Relationship between personality traits and perceived internalized stigma in bipolar patients and their treatment partners

Internalized stigma of mental disorders has significant negative outcomes for patients with bipolar disorder and their families. The aim of this study is to evaluate the association between personality traits and internalized stigma of mental disorders in bipolar patients and their treatment partners. Five different questionnaires were utilized in this study: (1) Demographic data questionnaire, (2) Millon Clinical Multiaxial Inventory-III (MCMI-III) for personality traits, (3) Internalized Stigma of Mental Illness (ISMI) for stigma, (4) Self Report Manic Inventory (SRMI) for mania and (5) Center for Epidemiological Studies-Depression Scale (CES-D) for depression. The scores of personality traits were combined to create externalizing and internalizing personality trait scores. Results showed that patients with bipolar disorder and their treatment partners both experienced internalized stigma of mental health disorders. There was a significant positive correlation between internalized stigma and internalizing personality traits, but not externalizing traits. In a multi-variate regression analysis, internalizing personality trait score was found to be a significant predictor of internalized stigma. In conclusion, patients with bipolar disorder and their treatment partners perceive higher level of internalized stigma of mental disorders if they have internalizing personality traits.