Irritable Temperament Research Articles

Tempéraments affectifs dans les troubles bipolaires et unipolaires : comparaison des profils tempéramentaux et relation avec les caractéristiques cliniques

Recent research postulated that temperaments represent the subclinical foundations of affective disorders, and an early clue for a recurrent, prebipolar disorder. Akiskal et al. operationalized five types of temperaments: depressive, hyperthymic, irritable, cyclothymic and anxious. The aims of this study were to compare the affective temperaments scores in patients with bipolar I, II and recurrent depression disorders and to explore the relation between temperaments scores and clinical features of those affective disorders. This was a comparative cross-sectional study, concerning three groups: patients with bipolar I disorder (BIP I) (n=31, 20 men and 11 women, mean age=42.0+/-10.1 years), patients with bipolar II disorder (BIP II) (n=18, 11 men and seven women, mean age=40.7+/-10.8 years) and patients with recurrent depressive disorder (RDD) (n=66, 28 men and 38 women, mean age=45.0+/-9.3 years). All patients were in remission of a major depressive episode. The affective temperaments were assessed by the Akiskal and Mallya Affective Temperament questionnaires. Hyperthymic temperament mean scores were higher in BIP I (10.8+/-5.4) and BIP II (10.3+/-5.5) groups compared to RDD group (5.5+/-4.0) (p<10(-3)). Depressive temperament mean score was significantly higher in RDD group (10.5+/-4.3), compared to BIP I (7.3+/-4.6) and BIP II (5.4+/-2.9) groups (p<10(-3)). Cyclothymic temperament mean score was higher in BIP II group (4.7+/-5.8) compared to BIP I (3.3+/-3.9) and RDD (2.5+/-3.9) groups, but this difference was not significant (p=0.08). No difference was found between the three groups concerning irritable temperament scores. Negative correlation was found between hyperthymic and depressive temperament scores in BIP I (r=-0.81, p<0.001) and RDD (r=-0.73, p<0.001) groups, but not in BIP II group. Concerning the clinical correlates with affective temperament scores, negative correlation was found between hyperthymic temperament score and number of depressive episodes in BIP II group (r=-0.53, p=0.02). Hyperthymic temperament score was associated with psychotic features in the last depressive episode in BIP I (p=0.01) and BIP II (p=0.008) groups and seasonal features in BIP II group (p=0.02). Moreover, cyclothymic temperament score was associated with psychotic (p=0.009) and seasonal features (p=0.03) in BIP II group. Despite the small sample sizes for our study groups, we can conclude that hyperthymic and cyclothymic temperaments characterized bipolar disorders and are correlated with other markers of bipolarity such as psychotic and seasonal features. Thus, temperament assessment might become a useful tool to predict bipolarity in association with those markers.

Non-right-handedness is associated with migraine and soft bipolarity in patients with mood disorders

Background There is a substantial body of data showing differences in the functioning of the two hemispheres in unipolar depressive and bipolar disorders. Migraine is a frequent co-morbid disorder in these patients, and it has been proposed that migraine may be associated with left-handedness. It would therefore be interesting to study migraine and handedness in a population of patients with mood disorders. Methods A total of 201 patients with an index episode of either major depression or mania were interviewed with a semi-structured interview based partly on DSM-IV criteria and partly on TEMPS-I for affective temperaments. The criteria of the Headache Classification Committee of the International Headache Society were used to establish the diagnosis of migraine. Hand preference was assessed using the Edinburgh inventory, and the patients were classified as having right-, left-, or mixed-handedness. Results In the whole group 117 patients had migraine (58%) and 59 (29%) were classified as having non-right hand preference. There was a significant increased prevalence of non-right-handedness in the migraine group (37% vs. 19%, p = 0.021, Chi-square test; OR 2.5; 95% CI 1.3 –4.8, p = 0.007). In patients with cyclothymic, hyperthymic or irritable temperaments the prevalence of non-right-handedness (42%) was significantly higher ( p = 0.013, Chi-square test; OR 2.2, 95% CI 1.2–4.3) compared to patients with a depressive or no affective temperament (24%). The prevalence of non-right-handedness was also significantly higher both in patients with co-morbid eating disorders (48% vs. 26%, p = 0.008 Chi-square test; OR 2.7, 95% CI 1.3–5.9, p = 0.01) and asthma (45% vs. 26%, p = 0.026 Chi-square test; OR 2.3, 95% CI 1.1–5.1, p = 0.029). Limitations Non-blind evaluation of affective diagnosis, migraine and handedness. Conclusions Our main finding supports the hypothesis that non-right-handedness is associated with migraine and bipolar affective temperaments (“soft bipolarity”) in a sample of patients with major affective disorders.

A case series on the hypothesized connection between dementia and bipolar spectrum disorders: Bipolar type VI?

BackgroundThe concept of bipolar spectrum disorders has opened therapeutic opportunities for patients with atypical and complex affective conditions. The literature has recently described several commonalities in pathophysiological processes of bipolar disorders and dementia. However, this connection has been insufficiently appreciated at the clinical level, in part because affective dysregulation in the elderly and, particularly in the dementia setting, is typically attributed either to secondary depressive states or otherwise relegated to a neurologically understandable behavioral complication resulting from cerebral disease. MethodsWe selected a case series of 10 elderly patients with late-onset mood and related behavioral symptomatology and cognitive decline without past history of clear-cut bipolar disorder. Clinical features, temperament, cognition, family history and pharmacological response were assessed to identify prototypical patients to illustrate the complexities of the dementia–bipolar interface. ResultsMixed and depressive mood symptoms were most commonly observed and all patients had been premorbidly of hyperthymic, cyclothymic and/or irritable temperaments. Most patients had a family history of bipolar disorder or disorders related to the bipolar diathesis. Symptoms were often refractory to or aggravated by antidepressants and acetylcholinesterase inhibitors, whereas mood stabilizers and/or atypical antipsychotics were beneficial, promoting behavioral improvement in all treated patients and marked cognitive recovery in five. LimitationsCase series with retrospective methodology. Conclusion and clinical implicationsPatients with cognitive decline and frequent mood lability might be manifesting a late-onset bipolar spectrum disorder, which we posit as type VI. We further posit that dementia and/or other biopsychosocial challenges associated with aging might release latent bipolarity in such individuals. Antidepressants, even drugs targeting dementia, might aggravate the behavioral dysregulation in these patients. Evaluation of premorbid temperament and/or family history of bipolarity and related disorders might help in broadening the clinical and biological understanding of such patients, providing a rationale for better customized treatment along the lines of mood stabilization and avoidance of antidepressants.

TEMPS-A (Rome): Psychometric validation of affective temperaments in clinically well subjects in mid- and south Italy

BackgroundOur aim was to study the psychometrics and factor structure replicability of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) in its Italian (Rome) Version. The questionnaire is a self-report 110-item measure that postulates five affective temperaments—the depressive, cyclothymic, irritable, hyperthymic, and anxious—which embody both strengths and liabilities along affective reactivity. In Italian, the TEMPS has previously been validated in its original 32-item version, the TEMPS-I (Pisa), one which did not yet include an anxious subscale. MethodsThe present sample consisted of 948 nonclinical subjects (27.39 years±8.22 S.D.). There were 476 men (50.2%: 28.56 years±8.63 S.D.) and 472 women (49.8%: 26.21 years±7.61 S.D.). Reliability and validity were assessed by standard psychometric tests. ResultsPrincipal Components Analysis with Varimax rotation resulted in a 3-factor solution: the first with highest explained variance (8.84%) represents Dysthymic, Cyclothymic and Anxious (Dys–Cyc–Anx) temperaments combined; the second identifies Irritable temperament (5.65% of variance); and the third Hyperthymic temperament (5.16% of variance). Cronbach Alpha coefficients for the three subscales were respectively .89, .77 and .74. The rates for the Dys–Cyc–Anx were 2.7%, and for the Irritable 3.1%. Despite the low rate of the Hyperthymic temperament (.2%), nonetheless 16% were between 1st and 2nd SD. Exploratory factor analysis revealed a positive loading combining Dys–Cyc–Anx with the Irritable; the Hyperthymic loaded negatively on this factor. In terms of dominant temperaments, based on z-scores, 2.7% were dysthymic, 1.7% cyclothymic, .7% hyperthymic, 3.5% irritable and 3% anxious. LimitationAlthough developed for self-rated use, the Italian authors nonetheless administered the TEMPS-A in an interview format. It is uncertain in what ways this procedure could have influenced our results, if any. Another limitation is that we did not assess test–retest reliability. ConclusionsThese data identify at least 3-factors, Dys–Cyc–Anx and Irritable (which are correlated), and Hyperthymic, which is uncorrelated with the others. Though our data are reminiscent of the neuroticism–extraversion distinction, importantly traits are operationalized in affective terms. Beyond the well-known relationship between the Dysthymic and Cyclothymic subscales and that between the Dysthymic and Anxious, the present data reveal a strong relationship between the Cyclothymic and Anxious as well, which is of great relevance for bipolar II. It is also provocative that much of hyperthymia (16%) in the +SD is between the 1st and 2nd SD, thereby “normalizing” this temperament in Italy, as previously reported by TEMPS-I (Pisa) from Northern Italy (and TEMPS-A from Lebanon and Argentina).

Examining Alternative Explanations of the Covariation of ADHD and Anxiety Symptoms in Children: A Community Study

Attention-deficit hyperactivity disorder (ADHD) is comorbid with a range of other disorders, including anxiety disorders. The aim was to examine different explanations for the covariation of these symptom domains in children according to the framework provided by (Lilienfeld, S. O. Comorbidity between and within childhood externalizing and internalizing disorders: Reflections and directions. Journal of Abnormal Child Psychology, 2003). The covariation of ADHD symptoms and anxiety symptoms were examined over a 12-month period in a community sample of 499 children aged 8-13; 91% were retained at 12-month follow-up. Dimensional assessments were conducted using questionnaires given to children, parents and teachers, with results analyzed via structural equation modeling. Positive associations between ADHD and anxiety symptoms were linked with inattention symptoms, were particularly pronounced for girls, and were linked via temperament and behavioral problems. No support for the hypothesis that ADHD symptoms predicted the development of anxiety symptoms over time or vice versa. ADHD symptoms (particularly inattention) and anxiety symptoms are covarying phenomena that are linked with an irritable temperament and disruptive behavior.

Affective temperament-types and suicidal behaviour

Background:As the different affective temperament-types (depressive, hyperthymic, cyclothymic, irritable and anxious) play a significant role in the development and symptom-formation of bipolar and unipolar major mood episodes, the aim of this study was to examine these affective temperaments in persons making suicide attempts.Method:Using the Hungarian version of the full-scale 110-item version of the TEMPS-A questionnaire. we compared the affective temperament profiles of 150 nonviolent (106 female and 44 male) suicide attempters (121 of them have had current major depressive episode) and 717 normal controls (438 females and 279 males).Results:Compared to controls, both female and male suicide attempters scored significantly higher in four of the five temperaments, containing mWre or less depressive component (depressive, cyclothymic, irritable and anxious). On the other hand, however, no significant difference between suicide attempters and controls was found for the hyperthymic temperament scores. Significantly higher rate of suicide attempters (135/150=90.0%) than controls (138/717=19.2%) have had some kind of dominant (mean score + 2 SD or above) affective temperament (p=0.0001).Conclusion:The findings support the strong relationship between depression and suicidal behaviour even on temperamental level, suggesting that hyperthymic temperament has no predisposing role for suicidal behaviour at least in case of nonviolent attempters. As current depression and dysregulated central serotonergic function are well-known suicide risk factors, these findings are also in good agreement with recent results on the significant relationship between the s allele of the serotonin transporter gene and depressive, cyclothymic, irritable and anxious temperaments, but not with hyperthymic temperament.

Psychometric properties of the Lebanese–Arabic TEMPS-A: A national epidemiologic study

Background Several measures have been proposed to evaluate temperament traits and their connection to psychopathology. One recent development in this area is the TEMPS-A (Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto-questionnaire). The purpose of this study is to psychometrically validate the Lebanese–Arabic version of TEMPS-A. Methods The TEMPS-A was adapted to Lebanese–Arabic and administered to 1320 Lebanese (593 males, 727 females, mean age of 43 ± 16 years) representing the adult population of Lebanon (total population: 4.2 million). This section was added by the Institute for Development Research and Applied Care (IDRAC) to the cross-national World Mental Health (WMH) initiative Lebanese chapter. Chronbach-α and Pearson's correlation were used to test the internal consistency and correlation among the subscales. Factor loadings were calculated using the principal component analysis with varimax rotation. Results Internal consistency varied between 0.66 (depressive) and 0.88 (anxious). As formulated by the originators of the instrument, five main factors emerged from the factor analysis, with some overlap between the depressive, the cyclothymic and the anxious temperaments, but almost none for the hyperthymic and irritable temperaments. The strongest correlation was observed between the anxious and the cyclothymic temperament subscales. Women had higher mean scores on the depressive, cyclothymic, and anxious subscales, whereas men scored higher on the hyperthymic subscale. There was a trend of increase by age in scores of the depressive subscale, and a trend of decrease in the cyclothymic and irritable subscales. Conclusion The Lebanese–Arabic TEMPS-A has a good internal consistency, is easy to use, and opens new and interesting research avenues in large epidemiologic national studies on temperament.

Temperament and job stress in Japanese company employees

This study aims to demonstrate the relevance of temperament to job stress. The subjects were 848 male and 366 female Japanese company employees. Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire version (TEMPS-A) and Munich Personality Test (MPT) were administered to assess temperaments, and the NIOSH Generic Job Stress Questionnaire (GJSQ) to assess job stress. We used hierarchical multiple linear regression analysis in order to demonstrate whether temperament variables added any unique variance after controlling the effects of other predictors such as gender, age and job rank. In all subscales of the GJSQ, temperament predicted a large share of the variance in job stress. Remarkably, for interpersonal relationship stressors, the temperament variables added greater variance than that predicted by gender, age and job rank. Summary of the hierarchical linear regression analysis showed that the irritable temperament was associated with the most prominent vulnerability, followed by cyclothymic and anxious temperaments. The schizoid temperament had difficulty in the area of social support. On the other hand, the hyperthymic temperament displayed significant robustness in facing most job stressors; the melancholic type showed a similar pattern to a lesser degree. The findings may be different in a clinical Japanese sample, or a cohort of healthy employees from a different cultural background. Temperament influences job stress significantly-indeed, it impacts on such stress with greater magnitude than age, gender and job rank in most areas examined. Temperament influences interpersonal relationship stressors more than workload-related stressors. Interestingly, in line with previous clinical and theoretical formulations, the hyperthymic and melancholic types actually appear to be "hyper-adapted" to the workplace.

The proposed factor structure of temperament and personality in Japan: combining traits from TEMPS-A and MPT

Background: In Japan, Kraepelin's descriptions on four “fundamental states” of manic depressive illness, the concepts of schizoid temperament by Kretschmer and obsessional and melancholic type temperament by Shimoda and Tellenbach have been widely accepted. This research investigates the construct validity of these temperaments through factor analysis. Method: TEMPS-A measured depressive, cyclothymic, hyperthymic and irritable temperaments and MPT rigidity, esoteric and isolation subscales measured, respectively, melancholic type and schizoid temperaments. Factor analysis was implemented with TEMPS-A alone and TEMPS-A and MPT combined data. Results: With TEMPS-A alone analysis, Factor 1 included 1 depressive, 11 cyclothymic and 12 irritable temperament items with a factor loading higher than 0.4; Factor 2 included 1 depressive and 10 hyperthymic temperament items; and Factor 3 included 2 depressive temperament items only. With TEMPS-A and MPT combined data, Factor 1 included 3 depressive, 11 cyclothymic and 5 irritable temperament items with a factor loading higher than 0.4 (interpreted as the central cyclothymic tendency for all affective temperaments along Kretschmerian lines and accounting for 11.7% of the variance); Factor 2 included 6 hyperthymic temperament items (6.22% of variance); Factor 3 included 1 cyclothymic, 7 irritable and 1 schizoid temperament items (interpreted as the irritable temperament and accounting for 3.24% of the variance); Factor 4 included 1 depressive temperament and 5 melancholic type items (interpreted as the latter, accounting for 2.66% of the variance); Factor 5 included 5 depressive temperament items, along interpersonal sensitivity and passivity lines, and accounting for 2.31% of the variance; and Factor 6 included 4 schizoid temperament items accounting for 2.07% of the variance. Limitation: We did not use the Kasahara scale, which some believe to better capture the Japanese melancholic type. Sample was 70% male. Conclusion: These analyses confirm the factor validity of depressive, hyperthymic, cyclothymic and irritable temperaments (TEMPS-A), as well as the melancholic type and the schizoid temperament (MPT). Traits of the depressive and melancholic types emerge as rather distinct. Indeed, our results permit the delineation of an interpersonally sensitive type that “gives in to others” as the core features of the depressive temperament; this is to be contrasted with the higher functioning, perfectionistic, work-oriented melancholic type. Mood dysregulation is represented by the largest number of traits in this population. Contrary to a widely held belief that the melancholic type with its devotion to work and to others is the signature temperament in Japan, cyclothymic traits account for the largest variance in this nonclinical population. Hyperthymic temperament, melancholic type and schizoid temperaments appear largely independent of mood dysregulation. In this Japanese population, TEMPS-A may identify temperament constructs more comprehensively when implemented with melancholic type and schizoid temperament question items added to it. The proposed new Japanese Temperament and Personality (JTP) Scale has self-rated items divided into six subscales.

Reliability and validity of TEMPS-A in a Japanese non-clinical population: application to unipolar and bipolar depressives

Background: In Japan, TEMPS-A has gathered much attention, because Kraepelin's concepts on “fundamental states” of mood disorder and temperaments have been widely respected. Method: TEMPS-A was translated into Japanese (and after the approval of the English back translation by H.S.A.), it was administered to 1391 non-clinical subjects, and 29 unipolar and 30 bipolar patients in remission. Of the non-clinical sample, 426 were readministered the instrument again in 1 month. A control group matched for gender and age was drawn from the non-clinical sample. Results: Regarding test–retest reliability, Spearman's coefficients for depressive, cyclothymic, hyperthymic, irritable and anxious temperaments were 0.79, 0.84, 0.87, 0.81 and 0.87, respectively; regarding internal consistency, Cronbach's α coefficients were 0.69, 0.84, 0.79, 0.83 and 0.87, respectively. The unipolar and bipolar groups showed significantly higher depressive, cyclothymic and anxious temperament scores than the control group. Curiously, the bipolar group showed significantly lower hyperthymic score than the control group; irritable temperament scores showed no significant differences. Depressive, cyclothymic, irritable and anxious temperament scores showed significant correlations with each other. Between the unipolar and bipolar groups, there was little difference regarding the temperament scores. Also the inter-temperament correlations showed the same pattern in the unipolar and bipolar groups. Limitation: The clinically well cohort was 70% male. Conclusion: TEMPS-A showed a high reliability and validity (internal consistency) in a Japanese non-clinical sample. By and large, the hypothesized five temperament structure was upheld. Depressive, cyclothymic and anxious temperaments showed concurrent validity with mood disorder. Irritable temperament may represent a subtype of depressive, cyclothymic or anxious temperaments. There may be a temperamental commonality between unipolar and bipolar disorders. TEMPS-A will open new possibilities for international research on mood disorder and personality traits.

Studies on a German (Münster) version of the temperament auto-questionnaire TEMPS-A: construction and validation of the briefTEMPS-M

Background: Based on classic German concepts of a continuum between depressive, hyperthymic, cyclothymic, and irritable temperaments and affective disorder (and adding an anxious type to the four), Akiskal and co-workers developed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego both in interview (TEMPS-I) and auto-questionnaire (TEMPS-A) versions. It is the aim of the present analyses to validate a brief German version of TEMPS-A. Methods: A total of 1056 students of the Westfälische-Wilhelms-Universität in Münster, Germany, filled out the long 110-item version of the TEMPS-A (Münster translation by Erfurth: TEMPS-M) modified into a five gradation Likert format and with the items randomized. Based on this data we constructed a brief version of the TEMPS-M. In a second study, a sample of 151 students were recruited who filled out the briefTEMPS-M twice, approximately 1 month apart. Results: Our psychometric procedures resulted in the retention of 35 items from the original 110. The proposed five-factor structure of the original TEMPS-A was upheld, with relatively few item reclassification (mainly due to some overlap between depressive and anxious traits). Internal consistency (Cronbach α values ranging from 0.69 to 0.84) and test-retest reliability were shown. Most importantly, all temperaments in the briefTEMPS-M correlated quite well (Pearson r values ranging from 0.49 to 0.72) with their respective original versions in the longer TEMPS-M. As for construct validity, significant correlation was shown with the Beck Depression Inventory for all but the hyperthymic temperament; the hyperthymic, cyclothymic and irritable correlated highest with the self-report Manic Inventory. Limitations: The study sample of university students was selective. Conclusions: We were able to construct a brief German version of the TEMPS-A auto-questionnaire. We submit this shorter version will be suitable for both clinical (psychiatric and general medical) and neurobiological research, as well as in studies on temperament features in selected populations, e.g., allowing comparisons between regions or different (German-speaking) countries.

The relationship of Kraepelian affective temperaments (as measured by TEMPS-I) to the tridimensional personality questionnaire (TPQ)

Background: There is considerable uncertainty in the current literature about the relationship between personality dimensions and affective temperaments. Method: We compared—in a non-ill 14–26-year-old Italian student population of 1010—the affective temperaments of classic psychiatry conceived as subaffective traits [and measured through the Temperament Assessment of Memphis, Pisa, Paris and San Diego-Interview Version (TEMPS-I) in the Akiskal and Mallya Operationalization] with Cloninger’s revised Tridimensional Personality Questionnaire (TPQ) deriving from the experimental psychology tradition. Results: The Depressive Temperament (DT) and Harm Avoidance (HA), loaded positively on the same canonical variate, whereas the hyperthymic (HT) strongly, and Novelty Seeking (NS) moderately, loaded negatively. In contrast, the Cyclothymic Temperament (CT) loaded highly positively on a second variate, on which both Novelty Seeking strongly and Harm Avoidance moderately loaded positively. Reward Dependence (RD), Persistence (P), and Irritable Temperament (IT) did not significantly relate to any temperamental and personality constructs. At a subdimensional level of TPQ ‘shyness with strangers’, ‘stoic rigidity’, ‘detachment’, ‘fear of uncertainty’, ‘reflection’, and ‘anticipatory worry’ correlated best with the DT. ‘Gregariousness’, ‘exploratory excitability’, ‘uninhibited optimism’, ‘attachment’, ‘confidence’, ‘extravagance’, ‘independence’, ‘vigor’, and ‘impulsiveness’ correlated best with HT. Lastly, ‘anticipatory worry’, ‘disorderliness’, ‘sentimentality’, and ‘fatigability’ correlated best with CT. Conclusions: The data provide concurrent validity to TEMPS-I and, as earlier suggested by Cloninger, indicate that (as expected) high HA and DT are related. High NS is both related to the HT and CT, and (somewhat unexpectedly), the CT is related to high HA. In a more theoretical vein, hyperthymic-novelty seeker can be predicted to be overrepresented among those with high achievement; on the other hand, a moody, restless disposition (a cyclothymic-harm avoidant type) may engage in outrageous behavior and be liable to negative affective arousal. We submit that these considerations could shed some light on the origin of socially adaptive behavior (‘sunny’ or sanguine types) on the one hand, and borderline conditions, anxious-hostile bipolarity (‘dark’ types) on the other.

Factorial structure and internal consistency of the German TEMPS-A scale: validation against the NEO-FFI questionnaire

Background: The purpose of the study was to evaluate the psychometric properties of the German version of the TEMPS-A questionnaire. Besides the reliability of the temperament scales, validity was the focus of interest. Therefore, the relationship between the TEMPS-A and the well-established personality questionnaire NEO-FFI, whose factors show theoretical overlap with temperaments, was investigated. Method: A total of 227 students aged between 20 and 42 years were asked to fill in both instruments. Reliability coefficients for the five temperament scales and correlations among the scales of both questionnaires were calculated, as well as multiple linear regression analysis with the five personality factors and gender as independent, and the five temperaments as dependent variables. Results: Reliability indices for the five temperament scales were satisfactory, with values ranging between 0.63 (depressive) and 0.76 (anxious). Women scored higher on depressive and anxious scales, whereas men had higher scores on hyperthymic temperament. Correlations within the temperament scales showed close relationships between depressive, anxious and cyclothymic temperaments; cyclothymic and irritable temperament were also related. The personality factors of the NEO-FFI predicted temperaments fairly well and explained between 41% and 58% of the variance; the main effects were exerted by neuroticism and extraversion, while the irritable temperament was primarily explained by low agreeableness. Limitation: The study sample was relatively small and selected. Conclusion: The TEMPS-A scale has sufficient reliability and good validity in a non-clinical sample. It opens new possibilities for clinical research at the interface of mental disorders, temperament and personality. Such research is in progress.

TEMPS-A scale in ‘mixed’ and ‘pure’ manic episodes: new data and methodological considerations on the relevance of joint anxious–depressive temperament traits

Background: Temperament is an important factor in affective illness. There is some indication that mixed episodes result from an admixture of inverse temperamental factors (e.g. depressive and/or anxious) to a manic syndrome. To test this hypothesis, which has been first formulated by Akiskal [Clin. Neuropharmacol. 15 (Suppl. 1A) (1992) 632–633], we compared the temperament of non-acute bipolar affective patients with and without the history of a previous mixed episode. Methods: Patients who had been hospitalized for a bipolar disorder were re-assessed at least 6 months after their last in-patient treatment. Those who met the criteria for a partially remitted or full affective or psychotic episode at re-assessment were excluded from the study. Data concerning illness history, current psychopathology (SCID-I interview), depression (BDI), mania (Self-Report Manic Inventory) and temperament (TEMPS-A scale) were obtained. Patients with and without a history of previous mixed episodes were compared. Results: Of 49 eligible former patients, 22 subjects with and 23 subjects without a former mixed episode in bipolar affective disorder fulfilled the inclusion criteria. Subjects suffering from bipolar affective disorder exhibited significantly more depressive and anxious and less hyperthymic temperament, if they had experienced a mixed episode previously. Concerning cyclothymic and irritable temperament, bipolar affective patients with a former mixed episode presented non-significantly higher scores. Patients with a former mixed episode presented with higher depression scores than patients without such a history. No group differences were found concerning current mania scores. Limitations: (1) This is a preliminary report from an ongoing study. (2) Temperament had not been assessed premorbidly. (3) Although group comparisons revealed significant differences, these did not seem great enough to fully explain the emergence of a mixed episode. Conclusion: Our findings support the study’s hypothesis that mixed episodes occur more often in subjects with an inverse temperament (e.g. depressive and anxious), although it cannot be ruled out that subsyndromal features of the bipolar illness had an effect on temperament assessment.

Pharmacology — a historical overview

The aim of this study was to assess whether different affective temperaments could be related to a specific mood disorder diagnosis and/or to different therapeutic choices in inpatients admitted for an acute relapse of their primary mood disorder.Hundred and twenty-nine inpatients were consecutively assessed by means of the Structured and Clinical Interview for axis-I disorders/Patient edition and by the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego auto-questionnaire, Young Mania Rating Scale, Hamilton Scale for Depression and for Anxiety, Brief Psychiatry Rating Scale, Clinical Global impression, Drug Attitude Inventory, Barratt Impulsiveness Scale, Toronto Alexithymia Scale, and Symptoms Checklist-90 items version, along with records of clinical and demographic data.The following prevalence rates for axis-I mood diagnoses were detected: bipolar disorder type I (BD-I, 28%), type II (31%), type not otherwise specified (BD-NOS, 33%), major depressive disorder (4%), and schizoaffective disorder (4%). Mean scores on the hyperthymic temperament scale were significantly higher in BD-I and BD-NOS, and in mixed and manic acute states. Hyperthymic temperament was significantly more frequent in BD-I and BD-NOS patients, whereas depressive temperament in BD-II ones. Hyperthymic and irritable temperaments were found more frequently in mixed episodes, while patients with depressive and mixed episodes more frequently exhibited anxious and depressive temperaments. Affective temperaments were associated with specific symptom and psychopathology clusters, with an orthogonal subdivision between hyperthymic temperament and anxious/cyclothymic/depressive/irritable temperaments. Therapeutic choices were often poorly differentiated among temperaments and mood states.Cross-sectional design; sample size.Although replication studies are needed, current results suggest that temperament-specific clusters of symptoms severity and psychopathology domains could be described.

A prospective study of stability and change over 2 years of affective temperaments in 14–18 year-old Italian high school students

Objective: It is generally accepted that temperament is not entirely stable, and that it changes with development, particularly in juvenile subjects; also, some temperaments are believed to be inherently more unstable. There is a great deal of current interest in Kraepelin's thesis that temperamental dysregulation in juvenile subjects represents the constitutional foundation from which the more florid episodes of manic-depressive illness arise; the cyclothymic, hyperthymic, depressive and irritable temperaments under consideration might represent the first observable phenotypes of the genetic diathesis for bipolarity. The analyses on the temperamental attributes in juvenile subjects were undertaken within this theoretical framework. Method: We evaluated 206 Italian high school students (14–18 years old) by means of a semi-structured affective temperament interview (TEMPS-I) at T0 and T1 two years later. Age, sex and psychometric properties of TEMPS-I raw scale score and weighted cut-off (as specially weighted linear combination of items) were used as predictive variables of stability. Results: Affective temperaments had a low to moderate level of stability, reaching 60% in the case of subjects with dominant cyclothymic temperament. The stability of the depressive temperament was primarily related to its weighted cut-off. The stability of the hyperthymic temperament appeared related to male sex, young age, and total scale score. Male sex represented the best stability predictor for the cyclothymic temperament as well. The group of subjects with an unstable depressive temperament showed a change toward the dominant cyclothymic temperament, whereas individuals with unstable hyperthymic temperamental traits moved on towards the dominant cyclothymic and depressive temperaments. The irritable construct was the least stable. Limitations: The infeasibility of a multiwave design represents the main limitation in evaluating the predictors of stability. Furthermore, in the present analyses, the size of the cyclothymic subsample was small. Conclusion: Our data indicate considerable fluctuation and instability in depressive and hyperthymic temperaments in mid-adolescence. The cyclothymic temperament appears to be the most stable. Interestingly, cyclothymic moodiness appears more persistent in juvenile males; likewise persistent hyperthymic traits appear more of a “male” attribute. Clinical and Public Health Implications: We submit that these sex-relevant traits could be important in the risk of developing juvenile bipolarity. Literature review indicates that clinical studies, albeit on small samples, have already provided some support for this thesis. Larger studies on epidemiological samples could be more informative from a public health perspective. A user-friendly affective temperament questionnaire, which is under development, is critical for the methodology of such studies. Our study indicates that the present version of the Akiskal–Malya questionnaire can be easily used post-pubertally. Age adjustment must be considered for younger subjects.

TEMPS-I: delineating the most discriminant traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population

Background: Although most personality constructs have been standardized in population studies, cyclothymic, depressive, irritable and hyperthymic temperaments putatively linked to mood disorders have been classically derived from clinical observations. Methods: We therefore administered the semi-structured affective temperament schedule of Memphis, Pisa, Paris and San Diego, Interview version (TEMPS-I) — in its original University of Tennessee operationalization — to 1010 Italian students aged between 14 and 26. The interview, administered in a randomized format, took 20 min per subject. Results: The semi-structured interview was easy to administer and well accepted by subjects, with no refusals. Principal component analysis with varimax rotation confirmed the hypothesized four-dimensional factor structure of the interview, with good to excellent internal consistency. Furthermore, discriminant analysis and multiple regression provided suggestions for identifying the traits that are most useful in defining a weighted cut-off for each of the temperaments (and which, with minor exceptions, are in agreement with those previously proposed on clinical grounds). In an additional exploratory factorial analysis, a depressive type which loads negatively on hyperthymia was distinguished from cyclothymia; the irritable temperament did not appear to have significant loading on either factor. Limitation: All the present analyses were internal to the scale itself, but ongoing studies are comparing them with other systems of temperament as well as testing their clinical cogency for affectively ill populations. Conclusion: While more work needs to be done on better operationalization of the irritable temperament, our findings overall support the existence — in a relatively young nonpatient population — of cyclothymic, depressive and hyperthymic types according to the classic descriptions of Kraepelin, Kretschmer and Schneider, in their TEMPS-I operationalization. Clinical implications: Coupled with a previous report identifying 10% of the same 14–26-year-old nonpatient population meeting an empirically defined statistical cut-off for these temperaments, the present data define the putative `fundamental states' that Kraepelin considered to be the personal predisposing anlagé of major affective disorders.

Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP)

Background: This paper presents the methodology and clinical data in mid-stream from a French multi-center study (EPIDEP) in progress on a national sample of patients with DSM-IV major depressive episode (MDE). The aim of EPIDEP is to show the feasibility of validating the spectrum of soft bipolar disorders by practising clinicians. In this report, we focus on bipolar II (BP-II). Method: EPIDEP involves training 48 French psychiatrists in 15 sites; construction of a common protocol based on the criteria of DSM-IV and Akiskal (Soft Bipolarity), as well as criteria modified from the work of Angst (Hypomania Checklist), the Ahearn-Carroll Bipolarity Scale, HAM-D and Rosenthal Atypical Depression Scale; Semi-Structured Interview for Evaluation of Affective Temperaments (based on Akiskal-Mallya), self-rated Cyclothymia Scale (Akiskal), family history (Research Diagnostic Criteria); and prospective follow-up. Results: Results are presented on 250 (of the 537) MDE patients studied thus far during the acute phase. The rate of BP-II disorder which was 22% at initial evaluation, nearly doubled (40%) by systematic evaluation. As expected from the selection of MDE by uniform criteria, inter-group comparison between BP-II vs unipolar showed no differences on the majority of socio-demographic parameters, clinical presentation and global intensity of depression. Despite such uniformity, key characteristics significantly differentiated BP-II from unipolar: younger age at onset of first depression, higher frequency of suicidal thoughts and hypersomnia during index episode, higher scores on Hypomania Checklist and cyclothymic and irritable temperaments, and higher switching rate under current treatment. Eighty-eight percent of cases assigned to cyclothymic temperament by clinicians (with a cut-off of 10/21 items on self-rated cyclothymia) were recognized as BP-II. Evaluation of this temperament by clinician and patient correlated at a highly significant level ( r=0.73; p<0.0001). Cyclothymia and hypomania were also correlated significantly ( r=0.51; p<0.001). Limitation: In a study conducted in diverse clinical settings, it was not possible to assure that clinicians making affective diagnoses were blind to the various temperamental measures. However, bias was minimized by the systematic and/or semi-structured nature of all evaluations. Conclusion: With a systematic search for hypomania, 40% of major depressive episodes were classified as BP-II, of which only half were known to the clinicians at study entry. Cyclothymic temperamental dysregulation emerged as a robust clinical marker of BP-II disorder. These data indicate that clinicians in diverse practice settings can be trained to recognize soft bipolarity, leading to changes in diagnostic practice at a national level.

The semi-structured affective temperament interview (TEMPS-I): Reliability and psychometric properties in 1010 14–26-year-old students

Background: The purpose of this study was to evaluate the reliability and psychometric properties of the Semistructured Affective Temperament Interview, and determine cut-offs for each temperament. Method: 1010 Italian students aged between 14 and 26 were evaluated by means of the Akiskal and Mallya criteria in a Semistructured Interview for depressive, cyclothymic, hyperthymic, and irritable temperaments. Results: This instrument has very good reliability and internal consistency. The percentage of subjects with a z-score higher than the second positive standard deviation (+2 SD) on the scales of depressive and cyclothymic temperaments are 3.6% and 6.3% (reaching scores of 7/7 and 9/10), respectively. Hyperthymic traits, on the other hand, are widespread in our sample: most subjects are included within the second positive standard deviation (+2 SD), and 8.2% of these reach a 7/7 score; therefore, the problem of defining a cut-off for this temperament is still open. By contrast, the irritable temperament is rare, conforming to a non-gaussian distribution, with 2.2% of cases above the second positive standard deviation (+2 SD). Limitation: The data are based on subject report without collateral information and external validation. Conclusion: This study contributes to more accurate definition of cut-offs for individual temperament scales. The standardization of the interview thus makes it possible to compare three out of four temperamental scales, showing the dominant temperamental characteristics for each subject. Prospective studies are needed to demonstrate the stability of these traits over time.

P.6.010 Association study of bipolar disorder and Msp I/Bal I RLFP at the dopamine D3 receptor gene

Objective: It is generally accepted that temperament is not entirely stable, and that it changes with development, particularly in juvenile subjects; also, some temperaments are believed to be inherently more unstable. There is a great deal of current interest in Kraepelin's thesis that temperamental dysregulation in juvenile subjects represents the constitutional foundation from which the more florid episodes of manic-depressive illness arise; the cyclothymic, hyperthymic, depressive and irritable temperaments under consideration might represent the first observable phenotypes of the genetic diathesis for bipolarity. The analyses on the temperamental attributes in juvenile subjects were undertaken within this theoretical framework. Method: We evaluated 206 Italian high school students (14–18 years old) by means of a semi-structured affective temperament interview (TEMPS-I) at T0 and T1 two years later. Age, sex and psychometric properties of TEMPS-I raw scale score and weighted cut-off (as specially weighted linear combination of items) were used as predictive variables of stability. Results: Affective temperaments had a low to moderate level of stability, reaching 60% in the case of subjects with dominant cyclothymic temperament. The stability of the depressive temperament was primarily related to its weighted cut-off. The stability of the hyperthymic temperament appeared related to male sex, young age, and total scale score. Male sex represented the best stability predictor for the cyclothymic temperament as well. The group of subjects with an unstable depressive temperament showed a change toward the dominant cyclothymic temperament, whereas individuals with unstable hyperthymic temperamental traits moved on towards the dominant cyclothymic and depressive temperaments. The irritable construct was the least stable. Limitations: The infeasibility of a multiwave design represents the main limitation in evaluating the predictors of stability. Furthermore, in the present analyses, the size of the cyclothymic subsample was small. Conclusion: Our data indicate considerable fluctuation and instability in depressive and hyperthymic temperaments in mid-adolescence. The cyclothymic temperament appears to be the most stable. Interestingly, cyclothymic moodiness appears more persistent in juvenile males; likewise persistent hyperthymic traits appear more of a “male” attribute. Clinical and Public Health Implications: We submit that these sex-relevant traits could be important in the risk of developing juvenile bipolarity. Literature review indicates that clinical studies, albeit on small samples, have already provided some support for this thesis. Larger studies on epidemiological samples could be more informative from a public health perspective. A user-friendly affective temperament questionnaire, which is under development, is critical for the methodology of such studies. Our study indicates that the present version of the Akiskal–Malya questionnaire can be easily used post-pubertally. Age adjustment must be considered for younger subjects.