Familiality of temperament in bipolar disorder: support for a genetic spectrum

Synthesising 30 years of clinical experience and scientific insight on affective temperaments in psychiatric disorders: State of the art

The concept of affective temperament has been extensively discussed throughout the history of psychopathology and represents a cornerstone in the study of mood disorders. This review aims to trace the evolution of the concept of affective temperaments (ATs) from Kraepelin's seminal work to the present day. In the 1980s, Akiskal redefined Kraepelin's concept of affective temperaments (ATs) by integrating the five recognized ATs into the broader framework of the soft bipolar spectrum. This conceptualization viewed ATs as non-pathological predispositions underlying psychiatric disorders, particularly mood disorders. Epidemiological and clinical studies have validated the existence of the five ATs. Furthermore, evidence suggests that ATs may serve as precursors to various psychiatric disorders and influence clinical dimensions such as disease course, psychopathology, and treatment adherence. Additionally, ATs appear to play a significant role in moderating phenomena such as suicide risk and stress coping. Incorporating an evaluation of temperamental bases of disorders into the multidimensional psychiatric diagnostic process could enhance treatment optimization and prognosis estimation.

Is a Genetic Variant associated with Bipolar Disorder Frequent in People without Bipolar Disorder but with Characteristics of Hyperactivity and Novelty Seeking?

Objective

The objective is to verify whether a genetic condition associated with bipolar disorder (BD) is frequent in old adults adapted to their environment, without BD, but with aptitudes for hyperactivity and novelty seeking (H/NS).

Methods

In this cross-sectional study, the study sample included healthy elderly people (40 participants, aged 60 or older) living in an urban area and recruited from a previous study on physical exercise and active aging, who were compared with 21 old adults with BD from the same area. The genetic methodology consisted of blood sampling, DNA extraction, real-time PCR jointly with FRET probes, and the SANGER sequencing method. The genetic variant RS1006737 of CACNA1C, found to be associated with bipolar disorder diagnosis, was investigated.

Results

The frequency of the RS1006737 genetic variant in the study group (H/NS) is not higher than in the BD group and is statistically significantly higher than in all the control groups found in the literature. However, the familiarity for BD is higher in old adults with BD than in the H/NS sample without BD. The risk of BD in the family (also considering those without BD but with family members with BD) is not associated with the presence of the genetic variant examined.

Conclusion

The study suggests that the gene examined is associated with characteristics of hyperactivity rather than just BD. Nevertheless, choosing to participate in an exercise program is an excessively general way to identify H/NS. The next step would be to identify the old adults with well-defined H/NS features with an adequate tool.

Effect of affective temperament on illness characteristics of subjects with bipolar disorder and major depressive disorder

BACKGROUND

Affective temperaments represent the stable, biologically determined substrates of mood disorders. The relationship between affective temperaments and bipolar disorder (BD) or major depressive disorder (MDD) has been described. However, the strength of such relationship should be tested while considering other factors influencing the diagnosis of BD/MDD. Literature also lacks a comprehensive description of the interplay between affective temperament and characteristics of mood disorders. The aim of the present study is to address these issues.

METHODS

This is a multicentric observational study including 7 Italian university sites. Five-hundred-fifty-five euthymic subjects with BD/MDD were enrolled and further divided in those with hyperthymic (Hyper, N = 143), cyclothymic (Cyclo, N = 133), irritable (Irr, N = 49), dysthymic (Dysth, N = 155), and anxious (Anx N = 76) temperaments. Linear, binary, ordinal and logistic regressions were performed to assess the association between affective temperaments and i) diagnosis of BD/MDD; ii) characteristics of illness severity and course.

RESULTS

Hyper, Cyclo and Irr were more likely to be associated with BD, together with earlier age of onset and presence of a first-degree relative with BD. Anx and Dysth were more associated with MDD. Differences in association between affective temperaments and characteristics of BD/MDD were observed for hospital admissions, phase-related psychotic symptoms, length and type of depression, comorbidity and pharmacological intake.

LIMITATIONS

Small sample size, cross-sectional design, recall biases.

CONCLUSION

Specific affective temperaments were associated to certain characteristics of illness severity and course of BD or MDD. Evaluation of affective temperaments might help a deeper understanding of mood disorders.

Affective temperaments mediate aggressive dimensions in bipolar disorders: A cluster analysis from a large, cross-sectional, international study

BACKGROUND

Affective temperaments show potential for aggressive behavior (AB) preventive strategies in bipolar disorder (BD). We aim to define intra-diagnostic subgroups of patients with BD based on homogeneous behaviors related to AB. Subsequently, to assess whether affective temperament dimensions may contribute to the presence and severity of AB.

METHODS

Patients with BD were recruited. AB was evaluated through the modified overt aggression scale (MOAS); affective temperaments were assessed with the TEMPS-A. A cluster analysis was conducted based on TEMPS-A and MOAS scores. Stepwise backward logistic regression models were used to identify the predictive factors of cluster membership.

RESULTS

799 patients with BD were enrolled. Three clusters were determined: non-aggressive (55.5 %), self-aggressive (18 %), and hetero-aggressive (26.5 %). Depressive, irritable, and anxious temperament scores significantly increased from the non-aggressive (lower) to the self-aggressive (intermediate) and the hetero-aggressive group (highest). A positive history of a suicide attempt (B = 5.131; OR = 169.2, 95 % CI 75.9; 377) and rapid cycling (B = -0.97; OR = 0.40, 95 % CI 0.17; 0.95) predicted self-aggressive cluster membership. Atypical antipsychotics (B = 1.19; OR = 3.28, 95 % CI 2.13; 5.06) or SNRI treatment (B = 1.09; OR = 3, 95 % CI 1.57; 5.71), psychotic symptoms (B = 0.73; OR = 2.09, 95 % CI 1.34; 3.26), and history of a suicide attempt (B = -1.56; OR = 0.20, 95 % CI 0.11; 0.38) predicted hetero-aggressive cluster membership.

LIMITATIONS

Recall bias might have affected the recollection of AB.

CONCLUSIONS

Clinical factors orientate the prevention of different ABs in BD. Affective temperaments might play a role in preventing AB since patients with more pronounced affective temperaments might have an increased risk of showing AB, in particular hetero-AB.

Temperament traits mediate the relationship between CACNA1C polymorphisms and bipolar disorder in cisgender women

The influence of temperament traits on bipolar disorder (BD) has been investigated. Both temperament traits and BD are partially genetically determined and seem to be influenced by variations in the CACNA1C gene. These variations presented a significant interactive effect with biological sex, although studies that evaluate this relationship are scarce. Here, we assessed the mediation effect of temperament traits on the relationship between two polymorphisms in the CACNA1C gene (rs1006737 and rs4765913) and BD according to sex. This is a cross-sectional study consisting of 878 Caucasian individuals (508 women and 370 men), aged 18-35, enrolled in a population-based study in the city of Pelotas, Southern Brazil. BD diagnosis was evaluated using the clinical interview MINI 5.0, and temperament traits were assessed via the application of the Affective and Emotional Composite Temperament Scale (AFECTS). Mediation models were tested using the modeling tool PROCESS (version 3.3) for SPSS. Bootstrapping-enhanced mediation analyses in women indicated that traits anger (39%) and caution (27%) mediated the association between the rs4765913 SNP and BD, while traits volition (29%), anger (35%), and caution (29%) mediated the association between the AA haplotype (rs1006737-rs4765913) and the BD. No effect was encountered for cisgender men. Our model revealed that paths from CACNA1C SNPs to BD are mediated by specific temperament traits in women, reinforcing the definition of temperament traits as endophenotypes.

Temperament and character dimensions as psychological markers of mood disorders in Polish adolescents and young adults-A prospective study

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Clinical research diagnostic criteria for bipolar illness (CRDC-BP): rationale and validity

BACKGROUND

In the 1970 s, scientific research on psychiatric nosology was summarized in Research Diagnostic Criteria (RDC), based solely on empirical data, an important source for the third revision of the official nomenclature of the American Psychiatric Association in 1980, the Diagnostic and Statistical Manual, Third Edition (DSM-III). The intervening years, especially with the fourth edition in 1994, saw a shift to a more overtly "pragmatic" approach to diagnostic definitions, which were constructed for many purposes, with research evidence being only one consideration. The latest editions have been criticized as failing to be useful for research. Biological and clinical research rests on the validity of diagnostic definitions that are supported by firm empirical foundations, but critics note that DSM criteria have failed to prioritize research data in favor of "pragmatic" considerations.

RESULTS

Based on prior work of the International Society for Bipolar Diagnostic Guidelines Task Force, we propose here Clinical Research Diagnostic Criteria for Bipolar Illness (CRDC-BP) for use in research studies, with the hope that these criteria may lead to further refinement of diagnostic definitions for other major mental illnesses in the future. New proposals are provided for mixed states, mood temperaments, and duration of episodes.

CONCLUSIONS

A new CRDC could provide guidance toward an empirically-based, scientific psychiatric nosology, and provide an alternative clinical diagnostic approach to the DSM system.

Korean Validation of the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire

OBJECTIVE

The Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) has been validated in more than 30 languages and is noted for its broad application in research and clinical settings. This study presents the first attempt to examine the reliability and validity of the TEMPS-A in Korea.

METHODS

A total of 540 non-clinical participants completed the Korean TEMPS-A, which was adapted from the original English version via a comprehensive translation procedure. Reliability was assessed using Cronbach's α, and associations between temperaments were examined using Spearman's correlation coefficient. Exploratory factor analysis (EFA) was performed, and differences in TEMPS-A scores between the gender- and age-based groups were examined using Kruskal-Wallis analysis.

RESULTS

The Korean TEMPS-A exhibited excellent internal consistency (0.70-0.91) and significant correlations between subscales. EFA resulted in a two-factor structure: Factor I (depressive, cyclothymic, irritable, and anxious) and Factor II (hyperthymic). Gender and age group differences were observed.

CONCLUSION

Overall, our results suggest that TEMPS-A is a reliable and valid measure of affective temperaments for the Korean population. This study opens new possibilities for further research on affective temperaments and their related traits.

Psychological symptoms during and after Austrian first lockdown in individuals with bipolar disorder? A follow-up control-group investigation

BACKGROUND

The coronavirus disease (COVID-19) pandemic, a global health crisis, has resulted in widespread socioeconomic restrictions including lockdown, social distancing, and self-isolation. To date, little is known about the psychological impact of the COVID-19 pandemic and lockdown on patients with bipolar disorder as a particularly vulnerable group.

METHODS

An online survey was conducted in Austria at two points of measurement (T1 April 2020 during the first lockdown vs. T2 May 2020 at post-lockdown). The sample comprises 20 patients with bipolar disorder (mean age = 49.4 ± 15.6 years) and 20 healthy controls (mean age = 32.7 ± 9.6 years). A 2 × 2 factorial design to compare two time points (T1 vs. T2) and two groups (patients vs. healthy controls) was used. Main outcome measures included the Brief Symptom Inventory-18 (BSI-18) and a (non-validated and non-standardized) assessment to determine COVID-19 fears and emotional distress due to social distancing. Multiple linear regression analyses were used to assess the longitudinal association of COVID-19 fears/emotional distress due to social distancing during lockdown (T1) and psychological symptoms after lockdown (T2).

RESULTS

At T1, results demonstrated higher scores in BSI-18 subscales depression, anxiety and global severity index as well as emotional distress due to social distancing in bipolar patients compared to controls. There was a significant time x group interaction in the BSI-18 subscale somatization showing a decreasing trend in patients with BD compared to controls. No time effects in BSI-18 subscales or COVID-19 fears/emotional distress due to social distancing were observed. Regression analyses showed that COVID-19 fears during lockdown predicted somatization, only in patients.

CONCLUSIONS

There was a connection between the lockdown measures and somatization symptoms observed in patients. When the first steps of easing the social restrictions in May 2020 took place, somatization decreased only in the bipolar compared to the control group. Higher COVID-19 fears during lockdown predicted later symptoms at post-lockdown. Long-term impacts of the COVID-19 pandemic need further investigations to improve current therapeutic approaches and prevent fears and distress during lockdown in individuals with bipolar disorder in times of crisis.

TEMPS-A (short version) plays a supplementary role in the differential diagnosis between major depressive disorder and bipolar disorder

AIM

Early differential diagnosis between patients with major depressive disorder (MDD) and bipolar disorder (BD), and subsequently providing appropriate treatments are essential. There has been increased interest regarding the association between affective temperaments and mood disorder diagnosis. Our aim was to analyze the diagnostic validity of affective temperaments assessed by the short version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-autoquestionnaire version (TEMPS-A), in mood disorder patients.

METHODS

Inpatients with MDD (n = 146) or BD (n = 128) completed the short version of TEMPS-A, and their depressive and manic symptom severities were evaluated. Data of MDD and BD patients were compared by univariable and multivariable analyses.

RESULTS

Of the five affective temperament dimensions, substantially higher hyperthymic, irritable, and cyclothymic temperament scores were found in BD patients than in MDD patients. Using a multivariable logistic regression model built using the severities of depressed and manic conditions, and the five affective temperament subscale scores as independent variables, we identified two factors statistically associated with BD diagnosis (anxious temperament and cyclothymic temperament). The recommended cutoff point for the 12 items evaluating cyclothymic temperament to differentiate BD from MDD was 8 or more 'True' items (sensitivity: 35.9%, specificity: 87.7%).

LIMITATIONS

Our design was cross-sectional, and therefore, there was a possibility of longitudinal diagnostic conversion of patients from MDD to BD.

CONCLUSION

Cyclothymic and anxious temperaments on the short version of TEMPS-A, identified as diagnostic differentiating factors between MDD and BD, may play supplementary roles in the early identification of BD.

COVID-19: Implications for bipolar disorder clinical care and research

The COVID-19 pandemic has posed significant challenges to health care globally, and individuals with bipolar disorder are likely disproportionally affected. Based on review of literature and collective clinical experience, we discuss that without special intervention, individuals with bipolar disorder will experience poorer physical and mental health outcomes due to interplay of patient, provider and societal factors. Some risk factors associated with bipolar disorder, including irregular social rhythms, risk-taking behaviours, substantial medical comorbidities, and prevalent substance use, may be compounded by lockdowns, social isolation and decrease in preventive and maintenance care. We further discuss implications for clinical research of bipolar disorders during the pandemic. Finally, we propose mitigation strategies on working with individuals with bipolar disorder in a clinical and research context, focusing on digital medicine strategies to improve quality of and accessibility to service.

Utility of TEMPS-A in differentiation between major depressive disorder, bipolar I disorder, and bipolar II disorder

Background

The association between temperament characteristics and mood disorders has gained much attention in recent years. The Temperament Evaluation of Memphis, Pisa, Paris and San Diego-autoquestionnaire version (TEMPS-A) is a self-rating scale measuring 5 affective temperament dimensions. In this study, we aimed to clarify whether each affective temperament of TEMPS-A is a differentiating factor between major depressive disorder (MDD), bipolar I disorder (BD-I), and bipolar II disorder (BD-II), and analyzed the utility of TEMPS-A in their differential diagnosis in a clinical setting.

Methods

A total of 346 patients (MDD, n = 176; BD-II, n = 112; BD-I, n = 58) filled out TEMPS-A. To assess the patients’ mood state at the time of temperament assessment, Patient Health Questionnaire-9 (PHQ-9) and Young Mania Rating Scale (YMRS) were also conducted.

Results

Multivariate logistic regression analysis demonstrated that cyclothymic and anxious temperament scores were significant factors differentiating the diagnosis of BD-I and BD-II from the diagnosis of MDD, and hyperthymic temperament score was a specific factor for the differential diagnosis of BD-I versus the diagnosis of BD-II.

Limitations

All of the patients included in our study received treatment in large general hospitals. Because the nature of the present study was cross-sectional, some MDD subjects in this study might have unrecognized BD-I/BD-II.

Conclusions

Cyclothymic and anxious temperament scores assessed by TEMPS-A might enable differentiation between MDD and BD, and hyperthymic temperament score on TEMPS-A might be useful in distinguishing between BD-I and BD-II.

Personality Structure and Attachment in Bipolar Disorder

BACKGROUND

An impairment of self and interpersonal functioning has an impact on coping strategies, regulation of affect and stress. Little is known so far about the impairment of personality functioning in patients with bipolar disorder (BD). The aim of this study is to assess the effects of personality structure and attachment in BD patients on the symptom burden.

METHODS

Forty-six patients with the diagnosis of BD were assessed by the 12-item Operationalized Psychodynamic Diagnosis Structure Questionnaire (OPD-SQS), the short version of Experience in Close Relationship-revised (ECR-R-D), and the Brief Symptom Inventory-18 (BSI 18) to determine the level of personality functioning, attachment patterns, and symptom load.

RESULTS

We observed positive correlations between personality difficulties, insecure attachment, and symptom load in patients with BD. A low level of structural integration and an insecure attachment style in patients with BD were accompanied by a significantly higher symptom load (r = 0.66, p ≤ 0.01). Interestingly, there were no significant differences in the structural integration (T(1.44) = -0.93, p = 0.357) and in the attachment style attachment related avoidance: (T(1,44) = 1.50, p = 0.140); attachment related anxiety (T(1,44) = -0.781, p = 0.439) of study participants with BD when compared to the normative value of the general population.

LIMITATIONS

Our limitations are the small sample size of our group and the lack of a control group.

CONCLUSION

In general, our results suggest that there is a link between personality structure and affective dynamics including depressive, anxiety, and somatization symptoms in BD. These findings underline the increasing importance of assessing personality structure and attachment for diagnosis and treatment planning of BD.

Creativity and Bipolar Disorder: A Shared Genetic Vulnerability

Bipolar disorder is a lifelong mood disorder characterized by extreme mood swings between mania and depression. Despite fitness costs associated with increased mortality and significant impairment, bipolar disorder has persisted in the population with a high heritability and a stable prevalence. Creativity and other positive traits have repeatedly been associated with the bipolar spectrum, particularly among unaffected first-degree relatives and those with milder expressions of bipolar traits. This suggests a model in which large doses of risk variants cause illness, but mild to moderate doses confer advantages, which serve to maintain bipolar disorder in the population. Bipolar disorder may thus be better conceptualized as a dimensional trait existing at the extreme of normal population variation in positive temperament, personality, and cognitive traits, aspects of which may reflect a shared vulnerability with creativity. Investigations of this shared vulnerability may provide insight into the genetic mechanisms underlying illness and suggest novel treatments.

Temperament, Character, and Defense Mechanism Changes With Treatment in Depression: A 9-Month Naturalistic Follow-up

The aim of this study was to evaluate the changes in temperament, character, and defense mechanisms with the treatment and remission in patients with major depressive disorder. The study was designed as a longitudinal observational follow-up study of patients with repeated measures at 0, 12, and 36 weeks. In baseline comparisons, the major depression group showed higher harm avoidance and novelty seeking scores and lower self-directness and mature defense styles scores compared with healthy controls. In the follow-up, temperament dimensions and neurotic defenses remained unchanged, mature defense styles and self-directness revealed significant increase, and immature defense styles revealed significant decrease. Although there was no significant difference in the defense styles, harm avoidance and novelty seeking scores remained higher in MDD patients compare with healthy controls in 36 weeks. Our findings regarding continuation of hierarchically upward improvement in defense mechanism after the remission may support importance of treatment after remission.

Comparison of the Emotion Regulation and Temperament Characteristics Between Depressive Patients With and Without Mixed Features

Introduction

"Depressive disorder with mixed features" has been included in the official classification in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Hypothesizing that difficulties in emotion regulation and affective temperament scores are higher in mixed depression comparing to pure depression, we aimed to evaluate the relationship between these phenomena and mixed symptoms.

Methods

Depressive patients diagnosed by a psychiatrist according to the DSM-5 and had not received any psychiatric treatment for the last 3 months, were included in the study. The Hamilton Rating Scale (HDRS), modified Hypomania Checklist (mHCL), Difficulties in Emotion Regulation Scale (DERS), and the TEMPS-A (Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionaire) were applied to all participants.

Results

Of the 63 participants, 40 (63.5%) were women. The mean age was 37.8±12.4 years while mean duration of education was 10.8±4.3 years. The proportion of mixed-depression assessed by the mHCL was 23.8% (n=15). No significant difference was found between the groups concerning gender, age, family history, age at onset of illness, the total number of episodes and temperament scores. Depressive patients with mixed features had significantly higher DERS nonacceptance subscale scores. Multiple regression analysis demonstrated that the cyclothymic temperament scale scores significantly affected the total mHCL scores.

Conclusion

In mixed depression group, higher scores in nonacceptance subscale seems to reflect a tendency to fluctuations in the emotional reactions of a person to the stress. Association between mixed depression, DERS nonacceptance subscale and cyclothymic temperament support the spectrum view that mixed depression is placed between pure depression and bipolarity.

Cyclothymic temperament: Associations with ADHD, other psychopathology, and medical morbidity in the general population

BACKGROUND

Cyclothymic temperament (CT) is an affective disposition often preceding bipolar disorder (BD), and is the most common affective temperament in patients with BD. In depressed patients, CT is a predictor for developing a bipolar course. In a clinical sample of adults with BD and attention deficit hyperactivity disorder (ADHD), CT was associated with higher loads of psychiatric symptoms, somatic comorbidity, impairment, and higher morbidity among first-degree relatives. We aimed to investigate the morbidity and occupational functioning of persons with CT in the general population.

METHODS

Randomly recruited Norwegian adults (n = 721) were assessed with a 21-item cyclothymic subscale from the TEMPS Autoquestionnaire. Self-reported data were collected on psychiatric symptoms, comorbidity, educational and occupational level, and known family morbidity.

RESULTS

Thirteen percent had CT associated with an increased prevalence of ADHD, BD, high scores on the Mood Disorder Questionnaire (MDQ), and childhood and adulthood ADHD symptoms. CT was found in 75% (p < .001) of the bipolar participants, and in 68% (p < .001) of those with a positive MDQ score. CT was associated with more anxiety/depression, substance and alcohol problems, lower educational and occupational levels, and having a first-degree relative with anxiety/depression, alcohol problems, ADHD, and BD.

LIMITATIONS

The CT subscale alone might include overlapping features with cyclothymic, anxious, irritable, and depressed temperaments, thus increasing the prevalence estimate of CT.

CONCLUSIONS

CT is a strong predictor of occupational failure and associated with more psychiatric impairment in the participants and their families. CT should be assessed in both mood disorder and ADHD patients.

Postpartum psychosis in bipolar disorder: no evidence of association with personality traits, cognitive style or affective temperaments

BACKGROUND

Bipolar disorder has been associated with several personality traits, cognitive styles and affective temperaments. Women who have bipolar disorder are at increased risk of experiencing postpartum psychosis, however little research has investigated these traits and temperaments in relation to postpartum psychosis. The aim of this study is to establish whether aspects of personality, cognitive style and affective temperament that have been associated with bipolar disorder also confer vulnerability to postpartum psychosis over and above their known association with bipolar disorder.

METHODS

Personality traits (neuroticism, extraversion, schizotypy and impulsivity), cognitive styles (low self-esteem and dysfunctional attitudes) and affective temperaments (including cyclothymic and depressive temperaments) were compared between two groups of parous women with DSM-IV bipolar I disorder: i) 284 with a lifetime history of postpartum psychosis within 6 weeks of delivery (PP group), ii) 268 without any history of mood episodes with onset during pregnancy or within 6 months of delivery (no perinatal mood episode, No PME group).

RESULTS

After controlling for current mood state, and key demographic, clinical and pregnancy-related variables, there were no statistically significant differences between the PP and No PME groups on any of the personality, cognitive style or affective temperament measures.

CONCLUSIONS

Personality traits, cognitive styles and affective temperaments previously shown to be associated with bipolar disorder in general were not specifically associated with the occurrence of postpartum psychosis. These factors may not be relevant for predicting risk of postpartum psychosis in women with bipolar disorder.

The affective temperament traits and pregnancy-related depression in mothers may constitute risk factors for their children with attention deficit and hyperactivity disorder

We investigated whether the affective temperaments of mothers and maternal depression before and during the index pregnancy are related to the development of Attention-Deficit Hyperactivity Disorder (ADHD) in their children. One hundred and twenty children were screened for the diagnosis of ADHD. After exclusion and inclusion criteria were applied for children and their mothers, we compared the mothers of children with (n = 63) and without ADHD (n = 60) in terms of affective temperament traits, depression before and during the index pregnancy, and some environmental risk factors. The rate of boys were significantly higher among children with ADHD compared to healthy controls. The mothers of children with ADHD had significantly lower education levels, more cigarette consumption during pregnancy, and more depression rates before the pregnancy than those of healthy children. Male gender (p = .002), Hamilton Depression Rating Scale (HDRS) (p = .002), cyclothymic (p = .022), irritable (p = .035) and anxious temperament scores (p = .016) significantly predicted the association between the mothers and their children with ADHD. Our findings might suggest that male child gender, the severity of depression at index pregnancy, higher cyclothymic, irritable, and anxious temperament scores in mothers may constitute as important risk factors for the development of ADHD in their children.Impact statementWhat is already known on this subject? Although the effects of maternal depression on ADHD were extensively investigated, the relationship between affective temperament traits of mothers and ADHD in their children has not been sufficiently examined. To investigate the roles of maternal affective temperament traits and pregnancy-related depression on offspring ADHD would help us to understand the etiopathogenic bases of ADHD.What do the results of this study add? Cyclothymic, irritable and anxious temperaments of mothers were significantly associated with the offspring ADHD after adjusting for the gender, maternal smoking, prepartum and antenatal depression.What are the implications of these findings for clinical practice and/or further research? These findings might demonstrate that some maternal affective temperaments and depression during pregnancy are suggestive of an inherited predisposition to ADHD in offsprings. Longitudinal studies are required to demonstrate the relationship between maternal affective temperament features and the development of affective illness in children with ADHD.

An International Society of Bipolar Disorders task force report: Precursors and prodromes of bipolar disorder

OBJECTIVES

To clarify the clinical features preceding the onset of bipolar disorder (BD) has become a public health priority for the prevention of high morbidity and mortality. BD remains frequently under- or misdiagnosed, and under- or mistreated, often for years.

METHODS

We assessed the predictive value of precursors and prodromes of BD. We assessed precursors of first-lifetime manic or hypomanic episodes with/without mixed features in retrospective and prospective studies. The task force evaluated and summarized separately assessments of familial risk, premorbid personality traits, retrospective, and prospective studies.

RESULTS

Cyclothymic features, a family history of BD, retrospectively reported attenuated manic symptoms, prospectively identified subthreshold symptoms of hypomania, recurrence of depression, panic anxiety and psychotic features, have been identified as clinical precursors of BD. The prodromal symptoms like [hypo]mania often appears to be long enough to encourage early identification and timely intervention.

CONCLUSIONS

The predictive value of any risk factor identified remains largely unknown. Prospective controlled studies are urgently needed for prevention and effective treatment.

The Association Between Affective Temperament Traits and Dopamine Genes in Obese Population

Studies indicate the heritable nature of affective temperament, which shows personality traits predisposing to the development of mental disorders. Dopaminergic gene polymorphisms such as DRD4, COMTVal158Met, and DAT1 have been linked to affective disorders in obesity. Due to possible correlation between the aforementioned polymorphisms and the affective temperament, the aim of our research was to investigate this connection in an obese population. The study enrolled 245 obese patients (178 females; 67 males). The affective temperament was assessed using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego autoquestionnaire (TEMPS-A). Genetic polymorphisms of DAT1, COMTVal158Met and DRD4 were collected from peripheral blood sample and determined using a polymerase chain reaction (PCR). Only in COMT polymorphisms, the cyclothymic and irritable dimensions were significantly associated with Met/Val carriers (p = 0.04; p = 0.01). Another interesting finding was the correlation between the affective temperament and age in men and women. We assume that dopamine transmission in heterozygotes of COMT may determine the role of the affective temperament in obese persons. Dopaminergic transmission modulated by COMT may be responsible for a greater temperament expression in obese individuals. To our knowledge, this is the first study describing the role of affective temperament in the obese population, but more research is needed in this regard.

Modeling human temperament and character on the basis of combined theoretical approaches

BACKGROUND

Although there are several models on the structure of human temperament, character and personality, the majority follow a single approach, providing a unilateral and overly theoretical construct which is unsuitable for clinical application. The current study aimed to develop a complex and comprehensive model of temperament and character by empirically combining relevant existing theories.

METHODS

The study included 734 healthy general population subjects aged 40.80 ± 11.48 years, who completed the TEMPS-A, TCI and NEO-PI-3 questionnaires. Data were analyzed in a multistep approach using Exploratory Factor analysis and forward stepwise linear regression.

RESULTS

The results yielded two highest order factors (Self and Self-Environment Interaction), six middle order factors (Emotional Self, Cognitive Self, Social Emotionality, Emotional and Cognitive Control, Ethical Emotionality and Behavior, Social Emotionality and Behavior) and 12 factors at the bottom (Ego Resiliency, Ego Strength, Intrapersonal Emotion, Personal Space Cognition, Interpersonal Cognition, Emotional Creativity, Externalized Interpersonal Emotion, Internalized Interpersonal Emotion, Emotional Motivation, Self-Discipline, Ethical Values and Ethical Behavior).

CONCLUSIONS

The current study developed a complex hierarchical model of temperament and character on the basis of empirical data from several temperament theories. An important feature of the new temperamental model is the frequent admixture of emotional and cognitive processes within the same module. This model expands the field to include elements probably corresponding to meta-cognition mechanisms and complex interactions between affective and cognitive control, which may provide useful in understanding and treating affective disorders as well.

The relationship between temperament and depression in Parkinson's disease patients under dopaminergic treatment

AIM

The risk factors for depressive symptoms in patients with Parkinson's disease (PD) under dopaminergic drug treatment are unclear. In this study, we examined whether some temperament traits are related to the presence of comorbid depression in PD patients, independent of the characteristics of illness and drug treatment.

METHODS

The participants in this study were 74 patients with idiopathic PD who were already treated with stable doses of levodopa or dopamine agonists. Depressive (n = 20) and non-depressive (n = 52) PD patients were assessed by means of the Unified Parkinson's Disease Rating Scale, Beck Depression Inventory, and Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto-questionnaire. The doses of levodopa and dopamine agonists were converted into levodopa equivalent daily dose.

RESULTS

The duration of treatment in the depressive group was significantly longer than in the non-depressive group (P = 0.03). The depressive patients had significantly higher scores on the Unified Parkinson's Disease Rating Scale than the non-depressive patients. Depressive (P < 0.0001), cyclothymic (P < 0.0001), anxious (P < 0.0001), and irritable (P = 0.02) temperament scores were significantly higher in depressive than in non-depressive patients. Hyperthymia scores were significantly higher in non-depressive patients than in depressive patients (P = 0.01). Logistic regression analysis revealed that depressive temperament traits (P = 0.03) significantly predicted the diagnosis of depression. In contrast, hyperthymic temperament seemed to be associated with the absence of depression (P = 0.006).

CONCLUSION

Our results indicated that the severity of PD and duration of dopaminergic treatment were not predictive of the development of depression in PD patients. Depressive temperament strongly predicted the development of depression in our sample. Hyperthymic temperament seemed to be associated with patients without depression. We suggest that depressive temperament traits seem to be related to depression, while hyperthymic temperament may have a protective role in the risk of depression in PD patients.

Affective temperament in inflammatory bowel diseases: Another brick in the wall of differentiation

Psychiatric disorders are significantly common complications among patients suffering from inflammatory bowel diseases (IBD). Affective temperament is a concept of core personality traits, which can decribe the vulnerability to mood disorders, therefore its evaluation might convey useful information about patients' mental status in autoimmune disorders. The aim of the study was to evaluate the affective temperament in patients with Crohn's disease (CD) and ulcerative colitis (UC) as characteristic features of these diseases, but also in the clinical course and the severity of anxiety and depression.Due to our knowledge this is the first study of this kind. The study enrolled 130 patients with IBD, including 68 with CD and 62 with UC. We used TEMPS-A to evaluate affective temperament and HADS scales to assess the intensity of depressive and anxiety symptoms. Harvey Bradshaw scale, Crohn’s Disease Activity Index (CDAI) and Mayo Score were used to evaluate clinical severity of the diseases. We observed significantly higher prevalence of depressive, cyclothymic and anxiety temperaments in CD patients compared to the control group. Harvey Bradshaw scale, CDAI and Mayo Self Report showed statistically significant outcomes, including significant positive correlations with depressive, cyclothymic and anxiety subscales of TEMPS-A, and negative correlation with the hyperthymic temperament in CD subjects. Our findings indicate significant differences between CD and UC due to temperament traits, and suggest distinct pathogenesis of mood disorders in IBD.

Opposing patterns of neuronal variability in the sensorimotor network mediate cyclothymic and depressive temperaments

Affective temperaments have been described since the early 20th century and may play a central role in psychiatric illnesses, such as bipolar disorder (BD). However, the neuronal basis of temperament is still unclear. We investigated the relationship of temperament with neuronal variability in the resting state signal-measured by fractional standard deviation (fSD) of Blood-Oxygen-Level Dependent signal-of the different large-scale networks, that is, sensorimotor network (SMN), along with default-mode, salience and central executive networks, in standard frequency band (SFB) and its sub-frequencies slow4 and slow5, in a large sample of healthy subject (HC, n = 109), as well as in the various temperamental subgroups (i.e., cyclothymic, hyperthymic, depressive, and irritable). A replication study on an independent dataset of 121 HC was then performed. SMN fSD positively correlated with cyclothymic z-score and was significantly increased in the cyclothymic temperament compared to the depressive temperament subgroups, in both SFB and slow4. We replicated our findings in the independent dataset. A relationship between cyclothymic temperament and neuronal variability, an index of intrinsic neuronal activity, in the SMN was found. Cyclothymic and depressive temperaments were associated with opposite changes in the SMN variability, resembling changes previously described in manic and depressive phases of BD. These findings shed a novel light on the neural basis of affective temperament and also carry important implications for the understanding of a potential dimensional continuum between affective temperaments and BD, on both psychological and neuronal levels.

Are affective temperaments determinants of quality of life in euthymic patients with bipolar disorder?

BACKGROUND

Bipolar disorder (BD) is a disabling illness that is associated with low quality of life (QoL). This low QoL goes further than mood episodes, which suggests that stable traits, such as affective temperaments, can cause functional impairment.

OBJECTIVE

Our study analyses the impact of affective temperaments on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of QoL in euthymic BD patients.

METHODS

A multicentre study was conducted in 180 euthymic BD patients and 95 healthy controls. Firstly, statistical analyses were performed to compare QoL and affective temperaments between the two groups. Secondly, Adaptive Lasso Analysis was carried out to identify the potential confounding variables and select the affective temperaments as potential predictors on the PCS and MCS of QoL in BD patients, as well as the control group.

RESULTS

QoL scores in terms of PCS and MCS in BD patients were significantly lower than in healthy individuals. Whereas anxious temperament, anxiety disorder comorbidity, and age were the best predictors of PCS impairment in BD patients, anxious temperament, subclinical depressive symptoms, and age were the best predictors of MCS impairment.

LIMITATIONS

Further longitudinal studies with unaffected high-risk relatives are needed to examine the potential interaction between affective temperament and psychopathology.

CONCLUSIONS

Anxious temperament has an impact on QoL in BD in terms of both the physical component and the mental component. Systematic screening of temperament in BD would give clinicians better knowledge of QoL predictors. Further research should allow more individualized treatment of BD patients based on temperamental factors.

Quantitative genetic analysis of anxiety trait in bipolar disorder

BACKGROUND

Bipolar disorder type I (BPI) affects approximately 1% of the world population. Although genetic influences on bipolar disorder are well established, identification of genes that predispose to the illness has been difficult. Most genetic studies are based on categorical diagnosis. One strategy to overcome this obstacle is the use of quantitative endophenotypes, as has been done for other medical disorders.

METHODS

We studied 619 individuals, 568 participants from 61 extended families and 51 unrelated healthy controls. The sample was 55% female and had a mean age of 43.25 (SD 13.90; range 18-78). Heritability and genetic correlation of the trait scale from the Anxiety State and Trait Inventory (STAI) was computed by using the general linear model (SOLAR package software).

RESULTS

we observed that anxiety trait meets the following criteria for an endophenotype of bipolar disorder type I (BPI): 1) association with BPI (individuals with BPI showed the highest trait score (F = 15.20 [5,24], p = 0.009), 2) state-independence confirmed after conducting a test-retest in 321 subjects, 3) co-segregation within families 4) heritability of 0.70 (SE: 0.060), p = 2.33 × 10^-14 and 5) genetic correlation with BPI was 0.20, (SE = 0.17, p = 3.12 × 10^-5).

LIMITATIONS

Confounding factors such as comorbid disorders and pharmacological treatment could affect the clinical relationship between BPI and anxiety trait. Further research is needed to evaluate if anxiety traits are specially related to BPI in comparison with other traits such as anger, attention or response inhibition deficit, pathological impulsivity or low self-directedness.

CONCLUSIONS

Anxiety trait is a heritable phenotype that follows a normal distribution when measured not only in subjects with BPI but also in unrelated healthy controls. It could be used as an endophenotype in BPI for the identification of genomic regions with susceptibility genes for this disorder.

A personality-based latent class typology of outpatients with major depressive disorder: association with symptomatology, prescription pattern and social function

BACKGROUND

While major depressive disorder (MDD) is considered to be a heterogeneous disorder, the nature of the heterogeneity remains unclear. Studies have attempted to classify patients with MDD using latent variable techniques, yet the empirical approaches to symptom-based subtyping of MDD have not provided conclusive evidence. Here we aimed to identify homogeneous classes of MDD based on personality traits, using a latent profile analysis.

METHODS

We studied 238 outpatients with DSM-IV MDD recruited from our specialized depression outpatient clinic and assessed their dimensional personality traits with the Temperament and Character Inventory. Latent profile analysis was conducted with 7 dimensions of the Temperament and Character Inventory as indicators. Relationships of the identified classes with symptomatology, prescription pattern, and social function were then examined.

RESULTS

The latent profile analysis indicated that a 3-class solution best fit the data. Of the sample, 46.2% was classified into a "neurotic" group characterized by high harm avoidance and low self-directedness; 30.3% into an "adaptive" group characterized by high self-directedness and cooperativeness; and 23.5% into a "socially-detached" group characterized by low reward dependence and cooperativeness and high self-transcendence. The 2 maladaptive groups, namely neurotic and socially-detached groups, demonstrated unique patterns of symptom expression, different classes of psychotropic medication use, and lower social functioning.

LIMITATIONS

Generalizability of the findings was limited since our patients were recruited from the specialized depression outpatient clinic.

CONCLUSIONS

Our personality-based latent profile analysis identified clinically meaningful 3 MDD groups that were markedly different in their personality profiles associated with distinct symptomatology and functioning.

Inhibited Temperament and Hippocampal Volume in Offspring of Parents with Bipolar Disorder

BACKGROUND

Prior studies have suggested that inhibited temperament may be associated with an increased risk for developing anxiety or mood disorder, including bipolar disorder. However, the neurobiological basis for this increased risk is unknown. The aim of this study was to examine temperament in symptomatic and asymptomatic child offspring of parents with bipolar disorder (OBD) and to investigate whether inhibited temperament is associated with aberrant hippocampal volumes compared with healthy control (HC) youth.

METHODS

The OBD group consisted of 45 youth, 24 of whom had current psychiatric symptoms (OBD⁺s) and 21 without any psychiatric symptoms (OBD^-s), and were compared with 24 HC youth. Temperament characteristics were measured by using the Revised Dimensions of Temperament Survey. Magnetic resonance imaging was used to measure hippocampal volumes. The association between temperament and hippocampal volumes was tested by using multiple regression analysis.

RESULTS

Compared with the OBD^-s group, the OBD⁺s group had significantly more inhibited temperament traits, less flexibility, more negative mood, and less regular rhythm in their daily routines. In contrast, the OBD^-s group was more likely to approach novel situations compared with OBD⁺s or HC groups. Within the OBD⁺s group, a more inhibited temperament was associated with smaller right hippocampal volumes.

CONCLUSIONS

In this study, symptomatic OBD were characterized by an inhibited temperament that was inversely correlated with hippocampal volume. Additional longitudinal studies are needed to determine whether inverse correlations between hippocampal volume and inhibited temperament represent early markers of risk for later developing bipolar disorder.

Do the Trajectories of Bipolar Disorder and Schizophrenia Follow a Universal Staging Model?

OBJECTIVE

The purpose of this study is to address the question of whether a universal staging model of severe psychiatric disorders is a viable direction for future research by examining the extant literature.

METHOD

A narrative review was conducted of the relevant historical, conceptual, and empirical literature pertaining to the clinical trajectory of bipolar disorder and schizophrenia and issues relevant to staging.

RESULTS

There is substantive evidence that classic recurrent bipolar disorder is separable from schizophrenia on the basis of family history, developmental and clinical course, treatment response, and neurobiological findings. However, because of the intrinsic heterogeneity of diagnostic categories that has been amplified by recent changes in psychiatric taxonomy, key distinctions between the groups have become obfuscated. While mapping risk and illness markers to emerging psychopathology is a logical approach and may be of value for some psychiatric disorders and/or their clinical subtypes, robust evidence supporting identifiable stages per se is still lacking. Presently, even rudimentary stages such as prodromes cannot be meaningfully applied across different disorders and no commonalities can be found for the basis of universal staging.

CONCLUSIONS

Advances in the prediction of risk, accurate early illness detection, and tailored intervention will require mapping biomarkers and other risk indicators to reliable clinical phases of illness progression. Given the capricious nature of mood and psychotic disorders, this task is likely to yield success only if conducted in narrowly defined subgroups of individuals at high risk for specific illnesses. This approach is diametrically opposite to that being promulgated by proponents of a universal staging model.

Factor analysis of temperament and personality traits in bipolar patients: Correlates with comorbidity and disorder severity

BACKGROUND

Temperament and personality traits have been suggested as endophenotypes for bipolar disorder based on several lines of evidence, including heritability. Previous work suggested an anxious-reactive factor identified across temperament and personality inventories that produced significant group discrimination and could potentially be useful in genetic analyses. We have attempted to further characterize this factor structure in a sample of bipolar patients.

METHODS

A sample of 1195 subjects with bipolar I disorder was evaluated, all with complete data available. Dimension reduction across two inventories identified 18 factors explaining 39% of the variance.

RESULTS

The two largest factors reflected affective instability and general anxiety/worry, respectively. Subsequent analyses of the clinical features associated with bipolar disorder revealed specificity for the factors in a predictable pattern. Cluster analysis of the factors identified a subgroup defined by a strong lack of general anxiety and low affective instability represented by the first two factors. The remaining subjects could be distinguished into two clusters by the presence of either more positive characteristics, including persistence/drive, spirituality, expressivity, and humor, or more negative characteristics of depression and anxiety.

LIMITATIONS

These analyses involved bipolar I subjects only and must be extended to other bipolar spectrum diagnoses, unaffected relatives, and individuals at risk.

CONCLUSIONS

These results suggest that temperament and personality measures access latent traits associated with important clinical features of bipolar disorder. By translating clinical variables into quantitative traits, we may identify subgroups of bipolar patients with distinct clinical profiles, thereby facilitating both individual treatment strategies and genetic analyses.

Relationship Between Temperament and Character Traits, Mood, and Medications in Bipolar I Disorder

INTRODUCTION

Bipolar I disorder is an illness causing mood shifts that can result in personality and character trait alterations. The relationship between mood and personality and character traits in bipolar I disorder is unclear at this time.

METHODS

We conducted a study from February 2009 to March 2010 that included 42 subjects with bipolar I disorder, which was confirmed using the Structured Clinical Interview for DSM-IV Axis I Disorders. Mood was assessed via the Young Mania Rating Scale (YMRS) and the 30-item Clinician-rated Inventory of Depressive Symptomatology (IDS-C). Temperament and character traits were assessed via the Temperament and Character Inventory (TCI). Multivariate analysis was used to test relationships between mood and temperament and character traits with the effects of possible cofactors taken into account (eg, age, gender, medications).

RESULTS

We noted a positive correlation between YMRS scores and persistence (P = .046) and a trend toward positive correlation with novelty seeking (P = .054). There was a positive correlation between higher IDS-C scores and harm avoidance (P < .001) and a negative correlation with self-directedness scores (P < .001). Antipsychotic use was positively correlated with the character trait self-directedness (P = .008), with a trend toward a positive correlation with reward dependence (P = .056). Lithium was negatively correlated with reward dependence (P = .047) and self-transcendence (P = .028), with a trend toward a negative correlation with novelty seeking (P = .053).

CONCLUSIONS

The findings of our study suggest that some personality and character traits may vary according to mood state and medications in patients with bipolar I disorder. Prospective and longitudinal studies are required to fully characterize the relationships between personality and character traits and mood state in bipolar I disorder.

A comparative meta-analysis of TEMPS scores across mood disorder patients, their first-degree relatives, healthy controls, and other psychiatric disorders

BACKGROUND

The Temperament Evaluation Memphis, Pisa, Paris and San Diego Auto-questionnaire (TEMPS) is validated to assess temperament in clinical and non-clinical samples. Scores vary across bipolar disorder (BD), major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), borderline personality disorder (BPD) and healthy controls (HCs), but a meta-analysis is missing.

METHODS

Meta-analysis of studies comparing TEMPS scores in patients with mood disorders or their first-degree relatives to each other, or to a psychiatric control group or HCs.

RESULTS

Twenty-six studies were meta-analyzed with patients with BD (n= 2025), MDD (n=1283), ADHD (n=56) and BPD (n=43), relatives of BD (n=436), and HCs (n=1757). Cyclothymic (p<0.001) and irritable TEMPS scores (p<0.001) were higher in BD than MDD (studies=12), and in MDD vs HCs (studies=8). Cyclothymic (p<0.001), irritable (p<0.001) and anxious (p=0.03) scores were higher in BD than their relatives, who, had higher scores than HCs. No significant differences emerged between ADHD and BD (studies=3);

CONCLUSION

Affective temperaments are on a continuum, with increasing scores ranging from HCs through MDD to BD regarding cyclothymic and irritable temperament, from MDD through BD to HC regarding hyperthymic temperament, and from HC through BD relatives to BD regarding cyclothymic, irritable and anxious temperament. Depressive and anxious temperaments did not differ between BD and MDD, being nonetheless the lowest in HCs. BD did not differ from ADHD in any investigated TEMPS domain.

LIMITATIONS

Different TEMPS versions, few studies comparing BD with ADHD or BPD, no correlation with other questionnaires.

Neuropsychological performance and affective temperaments in Euthymic patients with bipolar disorder type II

Affective temperament has been suggested as a potential mediator of the effect between genetic predisposition and neurocognitive functioning. As such, this report seeks to assess the extent of the correlation between affective temperament and cognitive function in a group of bipolar II subjects. 46 bipolar II outpatients [mean age 41.4 years (SD 18.2); female 58.9%] and 46 healthy controls [mean age 35.1 years (SD 18); female 56.5%] were evaluated with regard to their demographic and clinical characteristics, affective temperament, and neurocognitive performance. Crude bivariate correlation analyses and multiple linear regression models were constructed between five affective temperament subscales and eight neurocognitive domains. Significant correlations were identified in bipolar patients between hyperthymic temperament and verbal memory and premorbid IQ; cyclothymic temperament and attention; and irritable temperament, attention, and verbal fluency. In adjusting for potential confounders of the relationship between temperament and cognitive function, the strongest mediating factors among the euthymic bipolar patients were found to be residual manic and depressive symptoms. It is therefore concluded that affective temperaments may partially influence the neurocognitive performance of both healthy controls and euthymic patients with bipolar disorder type II in several specific domains.

A meta-analysis of temperament and character dimensions in patients with mood disorders: Comparison to healthy controls and unaffected siblings

BACKGROUND

Cloninger's psychobiological model of personality has been extensively applied to subjects affected by mood disorders (MOOD). However, most studies are widely heterogeneous in terms of sample size, methods of assessment, and selection of participants.

METHODS

We conducted a systematic review of literature and a random effects meta-analysis of studies comparing at least two of the following groups: (a) adults with a primary MOOD diagnosis (Bipolar Disorder (BP) or major depressive disorder (MDD)), (b) their unaffected siblings (SIB) or (c) healthy subjects (HS), and reporting quantitative results from the Tridimensional Personality Questionnaire (TPQ) or the Temperament and Character Inventory (TCI). Subgroup, sensitivity and meta-regression analyses were also conducted.

RESULTS

High Harm Avoidance and low Self-Directedness were consistently associated with MOOD and SIB samples. BP was characterized by higher scores in Novelty Seeking and Self-Transcendence than HS, SIB and MDD. Age seemed to have a negative effect on Novelty Seeking and a positive effect on Harm Avoidance, Cooperativeness and Self-Transcendence. An euthymic mood state was associated with reduced Harm Avoidance, but increased Reward Dependence, Self-Directedness and Cooperativeness.

LIMITATIONS

The quality of the included studies varied and was relatively low. Moreover, publication bias and heterogeneity in the distribution of effect sizes may also have limited our results.

CONCLUSION

High Harm Avoidance and Low Self-Directedness may be trait markers for MOOD in general, while high Novelty Seeking and high Self-Transcendence may be specific to BP. Future studies are needed to disentangle the state-trait effect of each personality dimension.

Early interventions for youths at high risk for bipolar disorder: a developmental approach

In recent decades, ongoing research programmes on primary prevention and early identification of bipolar disorder (BD) have been developed. The aim of this article is to review the principal forms of evidence that support preventive interventions for BD in children and adolescents and the main challenges associated with these programmes. We performed a literature review of the main computerised databases (MEDLINE, PUBMED) and a manual search of the literature relevant to prospective and retrospective studies of prodromal symptoms, premorbid stages, risk factors, and early intervention programmes for BD. Genetic and environmental risk factors of BD were identified. Most of the algorithms used to measure the risk of developing BD and the early interventions programmes focused on the familial risk. The prodromal signs varied greatly and were age dependent. During adolescence, depressive episodes associated with genetic or environmental risk factors predicted the onset of hypomanic/manic episodes over subsequent years. In prepubertal children, the lack of specificity of clinical markers and difficulties in mood assessment were seen as impeding preventive interventions at these ages. Despite encouraging results, biomarkers have not thus far been sufficiently validated in youth samples to serve as screening tools for prevention. Additional longitudinal studies in youths at high risk of developing BD should include repeated measures of putative biomarkers. Staging models have been developed as an integrative approach to specify the individual level of risk based on clinical (e.g. prodromal symptoms and familial history of BD) and non-clinical (e.g. biomarkers and neuroimaging) data. However, there is still a lack of empirically validated studies that measure the benefits of using these models to design preventive intervention programmes.

Impact of Irritability and Impulsive Aggressive Behavior on Impairment and Social Functioning in Youth with Cyclothymic Disorder

OBJECTIVE

Research on adults with cyclothymic disorder (CycD) suggests that irritability and impulsive aggression (IA) are highly prevalent among this population. Less is known about whether these behaviors might also distinguish youth with CycD from youth without CycD. Additionally, little is known about how irritability and IA relate to one another, and whether they are associated with different outcomes. This study aimed to compare irritability and IA across diagnostic subtypes to determine whether CycD is uniquely associated with these behaviors, and to assess how irritability and IA relate to youth social and general functioning.

METHODS

Participants (n = 459), 11-18 years of age, were recruited from an urban community mental health center and an academic outpatient clinic; 25 had a diagnosis of CycD. Youth and caregivers completed measures of IA and irritability. Youth and caregivers also completed an assessment of youth friendship quality. Clinical interviewers assessed youth social, family, and school functioning.

RESULTS

Youth with CycD had higher scores on measures of irritability and IA than youth with nonbipolar disorders, but scores were not different from other youth with bipolar spectrum disorders. Measures of irritability and IA were correlated, but represented distinct constructs. Regression analyses indicated that irritability was related to friendship quality (p < 0.005). Both IA and irritability were related to social impairment (ps < 0.05-0.0005) and Child Global Assessment Scale (C-GAS) scores (ps = 0.05-0.005). CycD diagnosis was associated with poorer caregiver-rated friendship quality and social functioning (ps < 0.05).

CONCLUSIONS

We found that irritability and aggression were more severe among youth with CycD than among youth with nonbipolar diagnoses, but did not differ across bipolar disorder subtypes. Among youth seeking treatment for mental illness, irritability and IA are prevalent and nonspecific. Irritability and IA were uniquely related to our outcomes of social and general functioning, suggesting that it is worthwhile to assess each separately, in order to broaden our understanding of the characteristics and correlates of each.

The Role of Temperament in the Etiopathogenesis of Bipolar Spectrum Illness

Bipolar disorder constitutes a challenge for clinicians in everyday clinical practice. Our knowledge concerning this clinical entity is incomplete, and contemporary classification systems are unable to reflect the complexity of this disorder. The concept of temperament, which was first described in antiquity, provides a helpful framework for synthesizing our knowledge on how the human body works and what determines human behavior. Although the concept of temperament originally included philosophical and sociocultural approaches, the biomedical model is dominant today. It is possible that specific temperaments might constitute vulnerability factors, determine the clinical picture, or modify the course of illness. Temperaments might even act as a bridge between genes and clinical manifestations, thus giving rise to the concept of the bipolar spectrum, with major implications for mental health research and treatment. More specifically, it has been reported that the hyperthymic and the depressive temperaments are related to the more "classic" bipolar disorder, whereas cyclothymic, anxious, and irritable temperaments are related to more complex manifestations and might predict poor response to treatment, violent or suicidal behavior, and high comorbidity. Incorporating of the concept of temperament and the bipolar spectrum into the standard training of psychiatric residents might well result in an improvement of everyday clinical practice.

The effect of temperament on the treatment adherence of bipolar disorder type I

BACKGROUND AND AIMS

Treatment adherence is one of the most important factors that may determine treatment response in patients with bipolar disorders (BD). Many factors have been described to be associated with treatment adherence in BD. Temperament that can influence the course of BD will have an impact on treatment adherence. The aim of this study is to investigate temperament effect on treatment adherence in euthymic patients with BD-I.

METHODS

Eighty patients with BD-I participated in the study. A psychiatrist used the Structured Clinical Interview for DSM-IV Axis-I Disorders to determine the diagnosis and co-morbidities. Hamilton Depression and Young Mania Rating Scale were used to detect the remission. We used the Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire and the 4-item Morisky Medication Adherence Scale to evaluate temperament and treatment adherence, respectively. The study group was divided into two groups as "treatment adherent" and "treatment non-adherent".

RESULTS

The cyclothymic and anxious temperament scores of the treatment non-adherent patients with BD-I were significantly higher than those of the treatment adherent group (p < 0.001, p = 0.006, respectively). Multiple linear regression analysis determined that cyclothymic temperament predicted treatment non-adherence (p = 0.009).

CONCLUSION

It should be kept in mind that BD-I patients with cyclothymic temperament may be treatment non-adherent and future studies should explore whether temperament characteristics deteriorate BD-I course by disrupting treatment adherence.

Influence of personality and neuropsychological ability on social functioning and self-management in bipolar disorder

A majority of bipolar patients (BD) show functional difficulties even in remission. In recent years cognitive functions and personality characteristics have been associated with occupational and psychosocial outcomes, but findings are not consistent. We assessed personality and cognitive functioning through a range of tests in BD and control participants. Three cognitive domains-verbal memory, facial-executive, and spatial memory-were extracted by principal component analysis. These factors and selected personality dimensions were included in hierarchical regression analysis to predict psychosocial functioning and the use of self-management strategies while controlling for mood status. The best determinants of good psychosocial functioning were good verbal memory and high self-directedness. The use of self-management techniques was associated with a low level of harm-avoidance. Our findings indicate that strategies to improve memory and self-directedness may be useful for increasing functioning in individuals with bipolar disorder.

Factor structure of the French version of the Hypomanic Personality Scale (HPS) in non-clinical young adults

BACKGROUND

Hypomanic Personality Scale (HPS) is a self-report questionnaire designed to identify vulnerable individuals at high risk of bipolar disorders in non-clinical samples. Our aim was to identify the factorial structure of HPS in a French non-clinical sample and to compare this with different factor solutions described in the literature. We carried out a survey in a French population using a French version of HPS.

METHODS

A total of 698 participants were included in the study. They completed the HPS, the Schizotypal Personality Questionnaire-Brief (SPQ-B), the Positive And Negative Affect Schedule (PANAS), and the Beck Depression Inventory (BDI-II). We tested the 1, 3 and 4-factor solutions and used a Confirmatory Factor Analysis to compare these with the factor solutions suggested by Rawling et al. and Schalet et al.

RESULTS

Goodness-of-fit indices showed that Schalet et al.'s solution "fits" our data better than Rawling et al.'s factorial solutions. HPS scores correlated with the PANAS Positive score and the SPQ-B total score. We confirmed the 3-factor structure of the HPS in a large non-clinical population of young adults and found consistent correlations with BDI, affectivity and schizotypal traits.

Temperament and character profiles in bipolar I, bipolar II and major depressive disorder: Impact over illness course, comorbidity pattern and psychopathological features of depression

BACKGROUND

Studies comparing temperament and character traits between patients with mood disorders and healthy individuals have yielded variable results.

METHODS

The Temperament and Character Inventory (TCI) was administered to 101 bipolar I (BP-I), 96 bipolar II (BP-II), 123 major depressive disorder (MDD) patients, and 125 HS. A series of generalized linear models were performed in order to: (a) compare the TCI dimensions across groups; (b) test any effect of the TCI dimensions on clinical features of mood disorders; and (c) detect any association between TCI dimensions and the psychopathological features of a major depressive episode. Demographic and clinical variables were also included in the models as independent variables.

RESULTS

Higher Harm Avoidance was found in BP-II and MDD, but not in BP-I. Higher Self-Transcendence was found in BP-I. Our models also showed higher Self-Directedness in HS, either vs MDD or BP-II. No association was found between any TCI dimension and the severity of symptoms. Conversely, a positive association was found between Harm Avoidance and the overall burden of depressive episodes during lifetime.

LIMITATIONS

The cross-sectional design and the heterogeneity of the sample may be the main limitations of our study.

CONCLUSION

In general, our sample seems to support the view of a similar profile of temperament and character between MDD and BP-II, characterized by high Harm Avoidance and low Self-Directedness. In contrast, patients with BP-I only exhibit high Self-Transcendence, having a near-normal profile in terms of Harm Avoidance or Self-Directedness.

A tale of two diatheses: Temperament, BIS, and BAS as risk factors for mood disorder

OBJECTIVE

Learning more about how biological traits, like temperament and sensitivity in the behavioral inhibition (BIS) and behavioral activation (BAS) systems, relate to mood pathology is consistent with the Research Domain Criteria initiative׳s goal of investigating mechanisms of risk.

METHOD

Korean young adults (n=128) and American young adults (n=630, of whom 23 has recent treatment for bipolar disorder, and 21for depression) completed self-report questionnaires, including the TEMPS-A, the BIS/BAS scales, Beck Depression Inventory (BDI), and Hypomanic Checklist (HCL-32). Linear regression quantified relations between mood symptoms, sample characteristics, temperament, and BIS/BAS.

RESULTS

Temperament styles explained 49% of the variance in BDI scores. BIS explained an additional 1% of the variance in BDI scores. BAS Fun and Reward (p<.01), in addition to cyclothymic and hyperthymic temperaments (p<.001) explained 21% of the variance in HCL-32 scores. Sample characteristics were not significant predictors in the full model.

LIMITATIONS

Differences in sample size, the cross-sectional study design, and lack of collateral report or behavioral measures of constructs are limitations.

CONCLUSIONS

Affective temperament and BIS/BAS are complementary but distinct constructs. Affective temperament, particularly cyclothymic, may represent a stronger diathesis for mood pathology, and seems potent irrespective of culture or diagnosis. Assessing temperament may help overcome some challenges in diagnosing mood disorders.

Confirmatory test of two factors and four subtypes of bipolar disorder based on lifetime psychiatric co-morbidity

BACKGROUND

The first aim was to use confirmatory factor analysis (CFA) to test a hypothesis that two factors (internalizing and externalizing) account for lifetime co-morbid DSM-IV diagnoses among adults with bipolar I (BPI) disorder. The second aim was to use confirmatory latent class analysis (CLCA) to test the hypothesis that four clinical subtypes are detectible: pure BPI; BPI plus internalizing disorders only; BPI plus externalizing disorders only; and BPI plus internalizing and externalizing disorders.

METHOD

A cohort of 699 multiplex BPI families was studied, ascertained and assessed (1998-2003) by the National Institute of Mental Health Genetics Initiative Bipolar Consortium: 1156 with BPI disorder (504 adult probands; 594 first-degree relatives; and 58 more distant relatives) and 563 first-degree relatives without BPI. Best-estimate consensus DSM-IV diagnoses were based on structured interviews, family history and medical records. MPLUS software was used for CFA and CLCA.

RESULTS

The two-factor CFA model fit the data very well, and could not be improved by adding or removing paths. The four-class CLCA model fit better than exploratory LCA models or post-hoc-modified CLCA models. The two factors and four classes were associated with distinctive clinical course and severity variables, adjusted for proband gender. Co-morbidity, especially more than one internalizing and/or externalizing disorder, was associated with a more severe and complicated course of illness. The four classes demonstrated significant familial aggregation, adjusted for gender and age of relatives.

CONCLUSIONS

The BPI two-factor and four-cluster hypotheses demonstrated substantial confirmatory support. These models may be useful for subtyping BPI disorders, predicting course of illness and refining the phenotype in genetic studies.

Relationships between chronotypes and affective temperaments in healthy young adults

BACKGROUND

Chronotype, an individual׳s preferred time for activity and sleep, has been known to be associated with affective disorders. Affective temperaments may be subclinical manifestations that represent a biological diathesis for affective disorders. Therefore, the aim of this study is to investigate the relationships between circadian preferences and affective temperaments.

METHODS

Six hundred and forty one healthy young adults (376 male, 265 female) completed the Korean Translation of Composite Scale of Morningness to measure diurnal preferences and the Temperament Scale of Memphis, Pisa, Paris and San Diego - Autoquestionnaire (TEMPS-A) to measure cyclothymic, depressive, hyperthymic, irritable, and anxious affective temperaments. Multivariate analyses of covariance were computed with the five affective temperaments as dependent variables, chronotype and gender as an independent variable, and age as a covariate.

RESULTS

One hundred and sixteen subjects were classified as having morning-type (18.1%), 402 as intermediate-type (62.7%), and 123 as evening-type (19.2%) circadian preferences. Evening-type was significantly associated with greater depressive, cyclothymic, irritable, and anxious temperaments, while morning-type was significantly associated with hyperthymic temperament.

LIMITATIONS

The present study only used self-report questionnaires to measure diurnal preference.

CONCLUSIONS

Evening-type subjects were more likely to have depressive, cyclothymic, irritable and anxious temperaments, whereas morning-types were more likely to have hyperthymic temperament. This relationship between chronotype and affective temperament might be important for vulnerability to affective disorders.

Temperament and prodromal symptoms prior to first manic/hypomanic episodes: results from a pilot study

BACKGROUND

Prodromal symptoms prior to first episode mania/hypomania have been reported. However, the relationship between temperament and manic/hypomanic prodromal symptoms has not been investigated. We hypothesized that subjects scoring higher on cyclothymic and irritable temperament scales show more manic/hypomanic prodromal symptoms.

METHOD

Euthymic patients diagnosed with bipolar-I or -II disorder within 8 years underwent retrospective assessments with the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-autoquestionnaire (TEMPS-A) and the Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R).

RESULTS

Among 39 subjects (36.1 ± 9.9 years, females = 59%, bipolar-I = 62%) 100% and 92.3% reported subthreshold mania (mean = 7.4 ± 2.9) or subthreshold depressive symptoms (mean = 2.4 ± 1.5), and 87.2% and 43.6% reported general psychopathology (mean = 3.2 ± 2.0) or subthreshold psychotic symptoms (mean = 0.7 ± 1.0) prior to their first hypo-/manic episode. Subjects with higher cyclothymic and irritable temperament scores showed more subthreshold symptoms prior to the first manic/hypomanic episode, mainly subthreshold hypo-/manic symptoms (cyclothymic temperament r = 0.430; p = 0.006; irritable temperament r = 0.330; p = 0.040), general psychopathology symptoms (cyclothymic temperament r = 0.316; p = 0.05; irritable temperament r = 0.349; p = 0.029) and subthreshold psychotic symptoms (cyclothymic temperament r = 0.413; p = 0.009). In regression analyses, cyclothymic temperament explained 16.1% and 12.5% of the variance of the BPSS-R total score (p = 0.045) and psychosis subscore (p = 0.029).

LIMITATIONS

Retrospective study, no control group, small sample size.

CONCLUSION

We present data, which indicate a relationship between cyclothymic and irritable temperament and prodromal symptoms prior to the first manic/hypomanic episode. These findings support the notion that assessing cyclothymic temperament to identify people at-risk of developing bipolar-I and -II disorder may help to increase the predictive validity of applied at-risk criteria.