Temperament and character traits in patients with bipolar disorder and associations with attempted suicide

Depression Research and Treatment has issued a second compendium of papers focused on temperament, character, and depression. The psychobiology theory of personality proposed by Cloninger is a currently prevailing theory of personality that has been extensively investigated in the context of many different types of mental and personality disorders. This special issue reports up-to-date research findings on the psychobiology theory and depression from different countries. The current issue consists of six reports. Miettunen and colleagues in Finland present findings from a longitudinal birth cohort study (N = 4941). Participants with depression at 31 years of followup had higher rates of harm avoidance (HA) than participants without any psychiatric disorders. Participants without any psychiatric history were followed for another 12 years. Those who subsequently developed depression had high HA in 1997. The authors hypothesize that high HA is a potential indicator for subsequent depression. This study only used temperament scales and thus no information was available on the association between character and depression. Students in senior high schools (N = 1234) who were invited to participate in an internet-based intervention program for depression were studied by Christian and colleagues in Norway. High HA and low self-directedness (SD) emerged as strong predictors of adolescent depression. Interestingly, use of the internet intervention program was associated with low reward dependence (RD) in addition to depression severity. Garcia and colleagues studied an adolescent population (N = 304) in Sweden. Based on positive affect (PA) and negative affect (NA) scores derived from the Positive Affect and Negative Affect Schedule, the participants were categorized into four groups: self-fulfilling (high PA and low NA), high affective (high PA and high NA), low affective (low PA and low NA), and self-destructive (low PA and high NA). The self-fulfilling group was characterized by higher persistence (PS), SD, and cooperativeness (CO) than the three other groups. The self-destructive group was characterized by high HA and RD. The authors claim character maturity (expressed as high SD and CO) is important for psychological well-being. In Japan, Lu and colleagues followed graduate students (N = 184) on two occasions separated by a five-month interval. In a structural regression model, they posited that trait anxiety and depression constructs were linked to high HA and low SD. Although trait anxiety and depression scores were moderately correlated with each other, these two constructs showed different associations with Temperament and Character Inventory (TCI) subscale scores. Thus, trait depression was linked to high self-transcendence (ST) whereas trait anxiety was linked to low RD, PS, and CO. The authors claim that character maturity is linked to trait rather than state aspects of depression and anxiety. Directly exposed survivors of the Oklahoma City bombing randomly selected from a bombing survivor registry (N = 151) were examined by North and colleagues in the USA. Posttraumatic stress disorder (PTSD) after the bombing was associated with low SD and CO together with high ST and HA. Postdisaster major depression (MD) was more prevalent among those with PTSD than those without it, but low SD and CO could not be predicted by post-disaster MD. The authors emphasized the importance of developing and validating measures of resilience. A unique measure of temperament, the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego (TEMPS), was used by Tei-Tominaga and colleagues to study job stress among employees in one Japanese company (N = 728). Depression was predicted by high levels of cyclothymic and anxious temperament traits even after controlling for the effects of work-related stressors such as demanding work conditions and overcommitment. These articles all indicate the importance of temperament and character traits in the development of depression among a variety of populations across different countries. Despite some differences between the studies, a common theme may be that low SD and high HA are predictors of depression either directly or being mediated by third variables. Toshinori Kitamura C. Robert Cloninger Andrea Fossati Jorg Richter

EPA-1788 – Psychological symptoms in menopause associate with higher harm avoidance and lower self-directedness

This is the first study exploring how temperament and character personality dimensions impact self-reported resilience in major depressive disorder (MDD) and bipolar disorder (BD). We included 130 euthymic patients with affective disorders (AFD; 66 MDD and 64 BD) and 134 healthy controls (HC). Connor and Davidson resilience scale and Temperament and Character Inventory (TCI-140) were administered. Multiple linear regressions and interaction analyses were performed. Mediation analyses examined if personality dimensions explained group differences in resilience. Resilience was lower in MDD and BD vs. HC and in MDD vs. BD, adjusting for sex, age and education. Higher resilience was predicted by lower harm avoidance (HA) and higher persistence (P) in AFD and MDD, lower HA in BD and higher P and self-directedness (SD) in HC. However, only HA and P had a group-specific effect on resilience in AFD vs. HC. In mediation analyses, specific TCI dimensions at least partially explained differences in resilience: HA, P and SD in AFD or MDD vs. HC; SD in BD vs. HC; P in BD vs. MDD. Concludingly, two temperament traits (HA, P) and a character trait (SD) predict resilience in AFD. Focusing on personality could identify sources of compromised resilience as potential treatment targets.

Personality is an essential variable in order to understand the course of Obsessive-Compulsive Disorder (OCD). Among the studies investigating the relationship between OCD and personality traits, the most common finding is that individuals diagnosed with OCD was reported to have higher levels of Harm Avoidance (HA) trait compared to healthy controls. In addition, OCD group was found to have lower scores regarding Self- Directedness (SD), Cooperativeness (C) or Novelty Seeking (NS). The patient group of the study consisted of patients were diagnosed with OCD by SCID-I scanning. The healthy control group had similar age, gender, and educational level characteristics as the patient group. The patients and the control group were asked to fill out a Sociodemographic Data Form, Temperament and Character Inventory (TCI), Beck Depression and Beck Anxiety Scales. For the patient group, Yale-Brown Obsessive-Compulsive Scale, and Yale-Brown Symptom Checklist were filled out by the clinician who conducted the psychiatric interview. Patients with OCD (n=70) were characterized by higher HA (p<0.001) scores and lower C (p=0.034), and SD (p<0.001) scores than the healthy control group (n=65). When comparing pure OCD patients (n=23) with the healthy control group, their HA scores were higher and the self-transcendence (ST) scores were lower. Compared to the healthy control group, OCD patients with psychiatric comorbidity (n=47) had a higher HA score and a lower SD score. Comorbid OCD patients' SD scores were lower and ST scores were higher compared to the patients with Pure OCD. No significant relationship was found between OCD severity and TCI subscales. Our findings indicate the importance of considering the presence of comorbid psychiatric diagnoses for the evaluation of personality dimensions in OCD patients. The assessment of temperament and character traits in OCD may provide clinical benefit in terms of predicting the prognosis and planning appropriate psychotherapeutic interventions.

Personality and behavioral changes in epilepsy are well documented. However, neither the quantitative characteristics nor the etiology of these changes is clear yet. Cloninger has developed a psychobiological personality model that provides a way to evaluate personality in a dimensional way. This study examined the relationship between epilepsy and Cloninger's dimensional psychobiological personality model. A total of 73 epilepsy outpatients and 79 healthy controls were examined using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders, the Turkish version of the Temperament and Character Inventory, and an epilepsy questionnaire. Epilepsy patients had higher harm avoidance (HA) and lower persistence, self-directedness (SD), and cooperativeness scores than healthy controls did. In epileptic subjects, there was no correlation between age and duration of epilepsy. Subjects with partial seizures had higher HA scores and lower SD scores than generalized ones. Comorbid depression was represented with lower SD scores. In multiple linear regression models, only major depressive disorder predicted lower scores of SD. This study confirms specific personality changes among epileptics according to Cloninger's dimensional personality model and indicates a relationship between the characteristics of epilepsy and psychiatric comorbidity.

Temperament and character influence on depression treatment outcome

Character and temperament in major depressive disorder and a highly anxious-retarded subtype derived from melancholia

ObjectiveThis study investigated how personality (Temperament, Character) influences the occurrence and onset age of Bipolar Disorder (BD). Unlike previous studies, Temperament and Character Inventory (TCI) dimensions as well as profiles were examined regarding BD onset age.MethodsWe recruited within 5 years 179 adults with prevalent BD (37.4% males, mean age 48.0 ± 12.0 years) attending a general hospital outpatient clinic, in euthymia during the previous 3 months, and 96 controls (36.5% males, mean age 40.4 ± 12.6 years), a convenience sample of community adults recruited via snowball sampling. All participants completed TCI-140. Associations of personality with diagnosis were investigated using logistic regressions while case-only linear and Cox regressions examined associations of personality with onset age. Analyses included TCI dimensions, continuous and binary (dichotomized utilizing Greek general population medians), and profiles (all possible combinations of Temperament or Character high/low binary dimensions), adjusting for potential confounders.ResultsIn logistic regressions, BD risk was associated with higher scores in Novelty Seeking (NS), Harm Avoidance (HA) and Self-Transcendence (ST) and lower in Self-Directedness (SD) and Cooperativeness (CO). In linear and Cox regressions, high NS indicated earlier onset compared to low (B=-4.70 [-8.10, -1.30]; HR = 1.60 [1.15, 2.22]), while high SD indicated delayed onset (B = 5.24 [1.87, 8.62]; HR = 0.57 [0.40, 0.79]). In exploratory profile analyses, Narcissistic (high NS, HA and Reward Dependence [RD]) and Histrionic (high NS, low HA, high RD) Temperament profiles and Cyclothymic (low SD, high CO, high ST) and Melancholic (low SD, CO and ST) Character profiles were associated with earlier BD onset, while the Reliable (low NS, low HA, high RD) Temperament profile and Bossy (high SD, low CO, low ST), Creative (high SD, CO and ST) and Organized (high SD, high CO, low ST) Character profiles were associated with delayed onset. These associations, however, lost statistical significance after correcting for multiple comparisons and should be interpreted cautiously.ConclusionThis study reaffirmed previous associations of TCI dimensions with BD risk, with two (NS, SD) also significantly relating for the first time to onset age. TCI profiles tentatively provided a more nuanced understanding of BD’s onset than dimensions but warrant further investigation in larger samples.

Objectives:The relationship between major depressive disorder (MDD) and, especially harm avoidance, self-directedness, and cooperativeness has been determined based on Cloninger’s psychobiological personality model; there are not enough studies in the literature on the role of the subdimensions. Therefore, the aim of this study was to compare the patients with MDD and healthy controls in terms of temperament and character traits and especially subdimensions and thus to determine the role and predictive value of temperament and character subdimensions in major depression patients.Methods:The sample of this cross-sectional study consisted of 105 participants, 65 of whom were MDD patients, and 40 healthy controls, who voluntarily agreed to participate in the study. Sociodemographic data form, temperament and character inventory, and Hamilton depression rating scale were administered to the participants.Results:Compared with healthy controls, patients with MDD had lower self-directedness (p<0.001), cooperativeness (p=0.017), persistence (p<0.001), self-transcendence (p=0.001), and higher harm avoidance (p<0.001) scores. While there was no significant difference in novelty seeking (p=0.774); it was determined that MDD patients got higher scores in “Impulsiveness” (p=0.013) and lower scores in “Exploratory excitability” (p=0.001) subscales. Reward dependence has been identified as the only personality trait that there was no significant difference between major depression patients and healthy controls (p=0.511). As a result of the logistic regression analysis performed to determine the predictors of temperament and character subdimensions in major depression patients, only three temperament and character traits “Fatigability, Purposefulness, and Spiritual Acceptance” were determined as significant predictors (p<0.001). Fatigability was determined to be a serious risk factor, increasing the probability of MDD 3.6 times (p<0.001); purposefulness and spiritual acceptance were found to be protective personality traits that together reduced the probability of MDD by 0.8 times (p<0.001).Conclusion:This study shows that the risk of developing MDD is increased in individuals with low self-directedness, cooperativeness, persistence, and self-transcendence profiles, and whereas with prominent Harm avoidance personality traits. Therapeutic interventions, especially considering the temperament and character traits of “Fatigability, Purposefulness, and Spiritual Acceptance” determined in our study, may contribute positively to MDD treatment.

Suicide and mood disorders (especially major depressive disorder (MDD) and bipolar affective disorder (BD)) represent a significant global health burden. Major depressive disorder and bipolar affective disorder have been associated with increased risk for suicide. Some specific suicide risk factors might be found in underlying individual personality traits. Specific personality features may predispose an individual to mood disorders (MDD or BD) hence increased suicide risk. The specificity of this research is in the assessment of personality features during the acute phase of illness immediately after suicide attempt which resulted in psychiatric inpatient treatment. The study included 119 unrelated Caucasian participants with MDD-severe depressive episode without psychotic symptoms (MDD) and BD-severe depressive episode without psychotic symptoms (BD-sDE). Both groups of patients with MDD and BD-sDE were divided into the suicide attempters and non-suicidal group. The diagnoses of the severe depressive episode without psychotic symptoms in major depressive disorder (MDD; F32.2) and bipolar disorder (BD-sDE; F31.4) were made according to ICD-10 (WHO 1992) diagnostic criteria. Methods of suicide attempts were also assessed according to ICD-10 and a self-report questionnaire, the Temperament and Character Inventory (TCI) was applied. The participants who exhibited suicide attempt had significantly higher scores on harm-avoidance (HA) (p<0.001), significantly lower score on persistence (PS) (p=0.037) and lower score, however not statistically significant, on novelty-seeking (NS) (p=0.319) regarding temperament dimensions. In character dimensions, the patients with suicidal attempt had significantly lower scores on self-directedness (SD) (p<0.001) and significantly lower scores on cooperativeness (CO) (p=0.001). Patients who had suicide attempt may have some significantly different personality traits than non-suicidal patients with mood disorders. The combination of high harm-avoidance (HA) and low self-directedness (SD) may be specific for depressive episode while the combination of high HA, novelty-seeking (NS), and self-transcendence (ST) with low SD may be related to suicide attempts during the depressive episode in bipolar disorder. The novelty-seeking (NS), self-transcendence (ST) and self-directedness (SD) may be specific for suicidal group of bipolar patients.

Cloninger's neuropsychopharmacological theory identifies four temperament traits and three character traits that are largely heritable and are associated with addictions. We tested whether these personality traits were associated with smoking behavior and predicted smoking cessation and tobacco withdrawal symptoms. We conducted an Internet cohort study in 2005-2009. The Temperament and Character Inventory (TCI, 226 items, French version) was assessed in 2,993 people (1,593 current, 969 former, and 419 never-smokers). Subsets of participants indicated their smoking status after 30 days (n = 1,452, 48.5%) and answered the TCI again and reported tobacco withdrawal symptoms after 61 days (n = 644, 21.5%). Compared with never- and former smokers, daily smokers had higher scores of Harm Avoidance (HA) and lower scores of Persistence and Self-Directedness (SD). Daily smokers had higher scores of Novelty Seeking than never-smokers. In daily smokers, the level of tobacco dependence was associated with higher scores of HA and lower scores of SD. In the 60 daily smokers who had stopped smoking after 61 days, after adjustment for tobacco dependence level and baseline tobacco withdrawal ratings, SD predicted lower scores of depressed mood and anxiety at 61-day follow-up and HA predicted higher scores of depressed mood at 61-day follow-up. Personality ratings did not predict smoking cessation at follow-up in daily smokers or relapse in former smokers. A consistent association was found between smoking and high HA and low SD. Knowledge about these associations may be useful to clinicians to tailor counseling.

An increasing incidence of mood disorders in adolescents and young adults is being observed. The assessment of personality traits seems to be an interesting tool in identifying early markers of major depression (MD) or bipolar disorder (BD) as well as predictors of the course of the disease. The aim of this study was to compare the personality profiles in young patients with MD and BD in acute and remitted mood states. Seventy-nine adolescents and young adults with mood disorder diagnoses (MD or BD) were included in the study. The participants were assessed based on structured diagnostic interviews and completed the Temperament and Character Inventory (TCI). The clinical evaluation was conducted during the acute episodes and after reaching the stabilized mood in the course of follow-up visits in a 2-year study observation. At baseline, MD patients had higher scores on the harm avoidance (HA) with more pronounced anticipatory worry and fatigability subscale than BD patients. Conversely, BD patients reached higher scores in the total self-directedness (SD) character dimension and its sub-dimensions. MD patients with acute depressive symptoms had higher scores in the HA dimension and its subscale: anticipatory worry, shyness, and fatigability compared with their euthymic states. No significant differences in TCI dimensions between baseline and euthymia in the BD subgroup were found, and no differences between euthymic MD and BD patients. Higher ST and SD sub-dimensions may constitute a personality profile specific to BD, while high HA seems to be related to major depression in both acute and remitted states in young patients.

Le modèle du tempérament et du caractère de Cloninger appliqué dans le trouble bipolaire de l’adulte : recension de la littérature d’une approche tempéramentale

Temperament and character traits in patients with bipolar disorder and associations with comorbid alcoholism or anxiety disorders

ABS TRACT: The common brain structures correlated with personality traits in healthy mothers and their daughters Objective: To investigate the heritability of personality traits related to brain regions by recruiting a group of healthy mothers with their daughters. Methods: Twenty-two right handed mother-daughter pairs who gave their informed consents were included in this study. All of the participants were screened with non-patient Turkish version of Structured Clinical Interview for DSM IV (Diagnostic and Statistical Manual of Mental Disorders) to rule out any current and past psychiatric disorder. The volunteers filled the TCI (Temperament and Character Inventory) and underwent MRI (Magnetic Resonance Imaging) for brain imaging in consecutive days. The MRI scans of the participants were obtained during their follicular phase to control menstrual effect on brain volume. Image analysis was performed using SPM 8 software (Statistical Parametric Mapping) running in MATLAB 7. Image processing was based on the VBM-DARTEL (Voxel Based Morphometry) method. Age and total brain volume were included as confounding factors. To obtain common brain structures correlated with personality traits in both groups, group x personality dimension interaction analyses were performed. Results: The daughters had higher education years and they scored significantly higher NS (Novelty Seeking) points compared to their mothers. The correlation analyses revealed that HA (Harm Avoidance) in temperamental traits, SD (Self-Directedness) and ST (Self-Transcendence) in character traits were correlated significantly within mother-daughter pairs. The common brain structures which were significantly interacted in different personality traits were: