Temperament and personality features in panic disorder with or without comorbid mood disorders

Temperament Clusters in Patients With Panic Disorder in Relation to Character Maturity

OBJECTIVE

This study explored whether temperament profiles are associated with psychological functioning and whether character maturity affects this association in patients with panic disorders (PD).

METHODS

A total of 270 patients with PD were enrolled in this study. Measurements included the Temperament and Character Inventory-revised-short (TCI-RS), a self-report version of the Panic Disorder Severity Scale (PDSS-SR), Beck Depression Inventory-II (BDI-II), and Spielberger State-Trait Anxiety Inventory (STAI). Cluster analysis was used to define the patients' temperament profiles, and the differences in discrete variables among temperament clusters were calculated using a one-way analysis of variance. An analysis of covariance was conducted to control for the impact of character maturity on psychological functioning among clusters.

RESULTS

We identified four temperament clusters of patients with PD. Significant differences in the PDSS-SR, BDI-II, STAI-state, and STAI-trait scores among the four clusters were detected [F(3, 262)=9.16, p<0.001; F(3, 266)=33.78, p<0.001; F(3, 266)=19.12, p<0.001; F(3, 266)=39.46, p<0.001]. However, after controlling for the effect of character maturity, the effect of cluster type was either eliminated or reduced ([STAI-state] cluster type: F(3, 262)=0.94, p>0.05; SD+CO: F(1, 262)=65.95, p<0.001, ηp2 =0.20).

CONCLUSION

This study enabled a more comprehensive and integrated understanding of patients by exploring the configuration of all temperament dimensions together rather than each temperament separately. Furthermore, we revealed that depending on the degree of character maturity, the psychological functioning might differ even within the same temperament cluster. These results imply that character maturity can complement inherently vulnerable temperament expression.

Gender-related distribution of personality disorders in a sample of patients with panic disorder

Objective

We examined gender differences in the frequency of DSM-IV personality disorder diagnoses in a sample of patients with a diagnosis of panic disorder (PD).

Method

One hundred and eighty-four outpatients with a principal diagnosis of PD (DSM-IV) were enrolled. All patients were evaluated with a semi-structured interview to collect demographic and clinical data and to generate Axis I and Axis II diagnoses in accordance with DSM-IV criteria.

Results

Males were significantly more likely than females to meet diagnoses for schizoid and borderline personality disorder. Compared to males, females predominated in histrionic and cluster C diagnoses, particularly dependent personality disorder diagnoses. A significant interaction was found between female sex and agoraphobia on personality disorder (PD) distribution.

Conclusions

Male PD patients seem to be characterized by more severe personality disorders, while female PD patients, particularly with co-morbid agoraphobia, have higher co-morbidity rates with personality disorders belonging to the ‘anxious-fearful cluster’.

Temperament and character in patients with acute abdominal pain

BACKGROUND

Several conditions presenting with abdominal pain are associated with specific personality factors although it is unclear if this is true also in emergency clinic settings.

OBJECTIVE

To study personality factors among patients with acute abdominal pain in an emergency ward.

METHODS

Consecutive patients (N = 165) with abdominal symptoms at an emergency clinic were administrated the Temperament and Character Inventory (TCI). Three main groups were identified; specific abdominal diagnoses, (N = 77), non-specific abdominal pain, (N = 67) and organic dyspepsia (N = 21). TCI results were compared between clinical groups and a control group (N = 122).

RESULTS

As compared to individuals with specific abdominal diagnoses and controls, those with organic dyspepsia were significantly more anxious (harm avoidance), (p = 0.003), and had lower ability to cooperate (cooperativeness) (p = 0.048 and p = 0.004 respectively). They were also significantly more unpretentious (self-transcendence) compared to individuals with specific abdominal diagnoses (p = 0.048), non-specific abdominal pain (p = 0.012) and controls (p = 0.004) and evidenced less mature character (sum of self-directedness and cooperativeness) compared to those with specific abdominal diagnoses and controls (p = 0.003).

CONCLUSION

Individuals seeking care at an emergency clinic with organic dyspepsia showed a distinguishable pattern of personality features that distinguished them from the other comparison groups. Therefore an evaluation of personality factors may add a new dimension to the diagnostic investigation in the emergency care of abdominal pain and contribute to the optimization of the treatment of organic dyspepsia.

The relationship between impulsivity and panic disorder-agoraphobia: The role of affective temperament

There are opinions regarding that impulsivity may play a role in the pathogenesis of neuropsychiatric disorders. The aim of this study was to investigate the relationship between impulsivity and panic disorder (PD) in the patient group, to compare impulsivity and affective temperamental traits between patients and healthy controls and to investigate whether there is a relationship between impulsivity and affective temperamental traits. Participants comprised 70 patients with PD and 58 healthy volunteers. The Panic Agoraphobia Scale (PAS), the Barratt Impulsiveness Scale (BIS-11) and the Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire (TEMPS-A) were applied. Patients have significantly higher scores in affective temperament (except hyperthymic) and attentional impulsiveness subscales than the healthy controls. Positive and negative correlations were found between some PAS and BIS-11 scores as well as correlations between especially cyclothymic, hyperthymic, irritable and anxious subscale scores of the TEMPS-A and the BIS-11 scores in the patient group. The results of this study indicate a relationship between impulsivity and PD. The correlations found between affective temperament dimensions and impulsivity suggest how affective temperamental traits may influence different impulsivity dimensions.

Reward and loss anticipation in panic disorder: An fMRI study

Anticipatory anxiety and harm avoidance are essential features of panic disorder (PD) and may involve deficits in the reward system of the brain, in particular in the ventral striatum. While neuroimaging studies on PD have focused on fearful and negative affective stimulus processing, no investigations have directly addressed deficits in reward and loss anticipation. To determine whether the ventral striatum shows abnormal neural activity in PD patients during anticipation of loss or gain, an event-related functional magnetic resonance imaging experiment using a monetary incentive delay task was employed in 10 patients with PD and 10 healthy controls. A repeated-measures ANOVA to identify effects of group (PD vs. Control) and condition (anticipation of loss vs. gain vs. neutral outcome) revealed that patients with PD showed significantly reduced bilateral ventral striatal activation during reward anticipation but increased activity during loss anticipation. Within the patient group, the degree of activation in the ventral striatum during loss-anticipation was positively correlated with harm avoidance and negatively correlated with novelty seeking. These findings suggest that behavioural impairments in panic disorder may be related to abnormal neural processing of motivational cues.

Association between personality traits and Escitalopram treatment efficacy in panic disorder

BACKGROUND

There is strong evidence to suggest that personality factors may interact with the development and clinical expression of panic disorder (PD). A greater understanding of these relationships may have important implications for clinical practice and implications for searching reliable predictors of treatment outcome.

AIMS

The study aimed to examine the effect of escitalopram treatment on personality traits in PD patients, and to identify whether the treatment outcome could be predicted by any personality trait.

METHOD

A study sample consisting of 110 outpatients with PD treated with 10-20 mg/day of escitalopram for 12 weeks. The personality traits were evaluated before and after 12 weeks of medication by using the Swedish universities Scales of Personality (SSP).

RESULTS

Although almost all personality traits on the SSP measurement were improved after 12 weeks of medication in comparison with the baseline scores, none of these changes reached a statistically significant level. Only higher impulsivity at baseline SSP predicted non-remission to 12-weeks treatment with escitalopram; however, this association did not withstand the Bonferroni correction in multiple comparisons.

LIMITATIONS

All patients were treated in a naturalistic way using an open-label drug, so placebo responses cannot be excluded. The sample size can still be considered not large enough to reveal statistically significant findings.

CONCLUSIONS

Maladaptive personality disposition in patients with PD seems to have a trait character and shows little trend toward normalization after 12-weeks treatment with the antidepressant, while the association between impulsivity and treatment response needs further investigation.

Temperament characteristics in patients with panic disorder and their first-degree relatives

AIM

Panic disorder is one of the highly heritable anxiety disorders; and temperament characteristics are considered predicting liability to panic disorder. Accumulating evidence suggests temperament characteristics are intermediate phenotypes for clinical conditions. Given this background, we aimed to investigate temperament characteristics in patients with panic disorder, their first-degree relatives, and healthy controls.

METHOD

Study sample consisted of 60 patients with panic disorder, 37 first-degree relatives of these patients, and 37 age, gender, and education level matched healthy controls (HC). SCID-I, the Panic Agoraphobia Scale, and the State and Trait Anxiety Inventory were applied to assess clinical characteristics of the patient group. Temperament characteristics were assessed using the Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire (TEMPS-A).

RESULTS

Anxious, depressive, cyclothymic, and irritable temperament scores of patients were higher than those of HC. There was no difference between the patients and the relatives, with the exception of higher anxious temperament scores in patients.

CONCLUSION

Overall, our findings suggest that anxious temperament characteristic might be a trait marker for liability to panic disorder. Further research with a prospective design in a larger sample is required to confirm our findings.

Temperament, character traits, and alexithymia in patients with panic disorder

BACKGROUND

The primary aim of the present study was to compare temperament and character traits and levels of alexithymia between patients with panic disorder and healthy controls.

METHODS

Sixty patients with panic disorder admitted to the psychiatry clinic at Fırat University Hospital were enrolled in the study, along with 62 healthy age-matched and sex-matched controls. The Structured Clinical Interview for DSM-IV axis I (SCID-I), Temperament and Character Inventory (TCI), Toronto Alexithymia Scale (TAS-20), and Panic Agoraphobia Scale (PAS) were administered to all subjects.

RESULTS

Within the temperament dimension, the mean subscale score for harm avoidance was significantly higher in patients with panic disorder than in controls. With respect to character traits, mean scores for self-directedness and cooperativeness were significantly lower than in healthy controls. Rates of alexithymia were 35% (n=21) and 11.3% (n=7) in patients with panic disorder and healthy controls, respectively. The difficulty identifying feelings subscale score was significantly higher in patients with panic disorder (P=0.03). A moderate positive correlation was identified between PAS and TAS scores (r=0.447, P<0.01). Moderately significant positive correlations were also noted for PAS and TCI subscale scores and scores for novelty seeking, harm avoidance, and self-transcendence.

CONCLUSION

In our study sample, patients with panic disorder and healthy controls differed in TCI parameters and rate of alexithymia. Larger prospective studies are required to assess for causal associations.

Distinctive clinical characteristics and suicidal tendencies of patients with anxious depression

This study evaluated clinical characteristics and suicidality of patients with anxious depression in a large cohort of samples. Data were collected from 1003 patients who were depressed. A total of 461 patients were diagnosed with anxious depression and 542 were diagnosed with nonanxious depression. After adjusting for the severity of depression, those in the anxious depression group had significantly younger onset age, had been suffering from depression for a longer period, were more likely to experience a recurrence, and obtained lower scores on a scale assessing quality of life. The anxious depression group was characterized by a significantly higher proportion of individuals reporting significant suicidal ideation and previous suicide attempts, and those in this group tended to obtain higher scores on the Scale for Suicide Ideation. The present findings that were drawn from detailed evaluation of suicidality strongly support previous results assessed only with the help of clinical reports. More attention should be paid to assess suicide risk in these patients.

Evaluation of personality traits in panic disorder using Swedish universities Scales of Personality

Personality factors may interact with development and expressions of panic disorder (PD). This study sought to identify differences in personality traits between patients with PD and healthy individuals and explore the relationships between personality domains and various demographic and clinical variables of PD. Personality traits were evaluated in 193 patients and 314 matched healthy subjects using the Swedish universities Scales of Personality (SSP). All SSP traits, except for detachment and physical trait aggression, were significantly deviated in PD group, as compared to healthy subjects. The SSP factors of neuroticism and aggressiveness, but not extraversion, were significantly higher in PD group than in controls. More pronounced aberrations in personality traits were observed in PD with affective comorbidity. Only few demographic and clinical variables were associated with SSP scores in PD group. These results add to the evidence of maladaptive personality disposition in patients with PD, particularly high neuroticism and manifest somatic trait anxiety. Use of SSP proved to add clinically relevant information on personality traits in patients with PD.

The association between bodily anxiety symptom dimensions and the scales of the Revised NEO Personality Inventory and the Temperament and Character Inventory

The association between anxiety disorders and different measures of personality has been extensively studied to further the understanding of etiology, course, and treatment, and to possibly prevent the development of anxiety disorders. We have proposed a hierarchical model of bodily anxiety symptoms with 1 second-order severity factor and 5 first-order factors: cardio-respiratory, gastro-intestinal, autonomic, vertigo, and tension. The aim of this study was to investigate whether personality traits were differentially related to distinct symptom subdimensions or exclusively related to the general severity factor. Structural equation modeling of data on 120 patients with a primary diagnosis of social phobia and 207 patients with a primary diagnosis of panic disorder was used to examine the association between anxiety symptom dimensions and the scales of the Temperament and Character Inventory and of the Revised NEO Personality Inventory. When both sets of personality measures were simultaneously modeled as predictors, the Revised NEO Personality Inventory scales, neuroticism and extraversion, remained significantly associated with the severity factor, whereas the association between the Temperament and Character Inventory dimensions, harm avoidance and novelty seeking, and the severity factor became nonsignificant. Harm avoidance was negatively associated with the vertigo first-order factor, whereas neuroticism was negatively associated with the cardio-respiratory first-order factor, indicating that personality factors may be differentially related to specific anxiety subdimensions.

Different temperament and character dimensions correlate with panic disorder comorbidity in bipolar disorder and unipolar depression

BACKGROUND

This study aimed to investigate temperament and character correlates of panic disorder (PD) comorbidity in euthymic patients with bipolar disorder (BD) or unipolar depression (UD).

METHODS

Temperament and character were assessed using the Temperament and Character Inventory Revised (TCI-R) in 181 patients (70 patients with BD-I, 51 patients with BD-II and 60 with UD) in a euthymic state for at least 2 months.

RESULTS

PD was diagnosed in 14.3% of BD-I patients, 31.4% of BD-II and 40% of UD. BD patients with PD, when compared with BD patients without PD, had higher scores on harm avoidance (OR=1.04; 95% CI=1.02-1.07; p=0.002). Patients with UD and PD, when compared to patients with UD without PD, had higher scores on social acceptance (OR=1.27; 95% CI=1.08-1.49; p=0.004).

CONCLUSION

Different temperament and character dimensions correlated with PD comorbidity in BD and UD patients, suggesting different underlying pathophysiological mechanisms.

Harm avoidance and self-directedness as essential features of panic disorder patients

OBJECTIVE

The purpose of the study is to compare the personality traits assessed with the Temperament and Character Inventory (TCI) between patients with panic disorder (PD) and a control group in a Brazilian sample.

METHODS

One hundred thirty-five patients with PD paired according to sex and age with 135 controls without any psychiatric disorders were assessed with the Mini International Neuropsychiatric Interview (MINI), a structured interview. Temperament and character were assessed with the TCI.

RESULTS

Consistently, patients with PD presented higher scores on the harm avoidance (HA) temperament scale (23.20 +/- 5.41 vs 15.21 +/- 4.92; P < .001) and lower scores on the self-directedness (SD) (27.81 +/- 7.25 vs 35.16 +/- 5.47; P < .001) if compared to the control group and has been associated independently from other TCI scales and confounders with PD. The multivariate logistic model containing HA and SD explains 38.6% to 51.4% of the differences between PD and controls.

CONCLUSIONS

Harm avoidance could be a good candidate to be heritable because it appears to be a consistent finding across current literature in anxious and depressed patients independent of their cultural context. Also, SD seems to be a key character characteristic of PD patients. The dimensional assessment is an interesting alternative for understanding the relationship between the psychobiologic bases of temperament and character and is highly related to the development of psychiatric syndromes.

Effect of pharmacological treatment on temperament and character in panic disorder

Temperament and character were evaluated in patients with panic disorder (PD) before and after 1 year of pharmacological therapy to verify whether personality characteristics change after treatment. Therefore, 65 PD patients and 71 healthy subjects participated in the study. All subjects were evaluated with the SCID-IV, the Temperament and Character Inventory (TCI), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram. The TCI was re-administered to the patients at the end of the study. At the end of the study, complete remission was achieved by 31 patients (R), whereas symptoms did not disappear in the remaining 34 patients (NR). Before treatment, NR patients showed higher levels of harm avoidance (HA) and lower levels of persistence (P), self-directedness (SD) and cooperativeness (C) than healthy controls. Only HA levels were higher than normal in R, although they were significantly lower in R than in NR patients. These differences persisted after treatment. However, in NR patients the levels of SD and C worsened, whereas the difference between R patients and controls in HA levels (higher in R patients than in controls) disappeared after controlling the effect of residual phobic anxiety (higher than normal in R patients). Our data suggest that the high levels of HA found after remission may depend on the subsyndromal residual phobic symptoms, observed in R patients. Moreover, the persistence of anxious symptoms may have worsened the low levels of SD and C observed before treatment in patients who did not achieve remission.

The effect of temperament and character on response to selective serotonin reuptake inhibitors in panic disorder

OBJECTIVE

In this prospective study, temperament and character were evaluated in patients with panic disorder (PD), before 1 year of medication therapy, to verify whether these factors influenced the outcome of treatment.

METHOD

Seventy-one PD patients were evaluated with the SCID-IV, the Temperament and Character Inventory (TCI), the SCL-90, the Ham-A and the Ham-D. Patients were treated with pharmacotherapy and were evaluated monthly over 1 year.

RESULTS

Before treatment, non-remitted patients showed higher levels of harm avoidance (HA) and lower levels of persistence (P), self-directedness (SD) and cooperativeness (C), whereas remitted patients showed only higher levels of HA. After controlling the effect of the confounding variables, the likelihood to achieve remission was positively related to SD score (OR = 1.12; P = 0.002), particularly 'self-acceptance' SD dimension (OR = 1.30; P = 0.02).

CONCLUSIONS

Our data suggest that in PD: i) the evaluation of personality, using the Cloninger's model, confirms the presence of personality pathology as one predictor of non-response to treatment; ii) in patients with low SD a combination of medication and cognitive-behaviour therapy should be the most effective treatment.

The effect of pharmacotherapy on personality disorders in panic disorder: a one year naturalistic study

BACKGROUND

In this prospective study, Personality Disorders (PersD) were evaluated in patients with Panic Disorder (PD), before and after one year of pharmacotherapy to verify whether personality characteristics changed after treatment.

METHOD

Sixty PD patients and 60 sex and age-matched normal controls participated in the study. All subjects were evaluated with the SCID-IV, the Structured Interview for DSM-IV Personality Disorders (SIDP), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram and were evaluated monthly for one year to assess the remission of symptoms. The SIDP was re-administered to the patients at the end of the study.

RESULTS

Before treatment, PD patients showed a higher prevalence (60%) of PersD than normal subjects (8%). After treatment, PersD rate decreased (43%) due to the reduction of the rate of paranoid, avoidant and dependent PersD. When the effect of the treatment on personality traits was evaluated, we found that avoidant traits decreased only in remitted patients, paranoid traits decreased both in remitted and in non-remitted patients, and dependent traits decreased only in patients with major depression comorbidity.

LIMITATIONS

The small sample size and the short length of the follow-up period of our study suggest caution in the generalization of our results.

CONCLUSIONS

In our PD patients, an improvement of symptoms was associated with a reduction of paranoid, avoidant and dependent traits, with a normalization of paranoid traits and a persistence of avoidant and dependent characteristics. Therefore, our data suggest that in PD patients not only paranoid traits but also avoidant and dependent traits show, at least in part, a state phenomenon.

Personality disorders and the trimensional personality questionnaire factors in major depressive disorder

We assessed the potential relationship between personality disorder (PD) clusters, as assessed by the SCID-II, and temperamental traits assessed by the Tridimensional Personality Questionnaire (TPQ) among a well-characterized, unmedicated cohort of outpatients with major depressive disorder (MDD). The TPQ and SCID-II were administered to 263 depressed outpatients (mean age = 39.9 +/- 10.5 years; women = 139, 53%; initial 17-item Hamilton Rating Scale for Depression = 19.6 +/- 3.4) who currently met criteria for MDD and who were enrolled in an 8-week treatment trial. The multiple linear regression method was used to evaluate the relationship between TPQ factors and personality disorder clusters, controlling for age, gender, and initial 17-item Hamilton Rating Scale for Depression score as necessary. Among outpatients with MDD, meeting criteria for a Cluster A PD diagnosis was related to high harm avoidance (HA) scores, as well as low reward dependence and novelty seeking (NS) scores. Additionally, high HA scores were associated with meeting criteria for a Cluster C PD diagnosis, while high NS scores were associated with meeting criteria for a Cluster B PD diagnosis. Certain temperament traits, especially HA and NS, appear to be associated with specific patterns of personality clusters among depressed patients.

Is harm avoidance an essential feature of patients with panic disorder?

OBJECTIVE

Previous studies on the Tridimensional Personality Questionnaire (TPQ) in patients with panic disorder (PD) have failed to support Cloninger's hypothesis that PD is not specifically related to any of the 3 personality dimensions. In most studies, patients with PD had clearly higher harm avoidance (HA) scores. This finding, however, could be biased by comorbid personality disorders in the samples. In the present study, we examined the TPQ scores in 43 patients without comorbid personality disorders.

METHOD

The differences between PD patients without personality disorders and control subjects were examined by hierarchical analyses of variance.

RESULTS

We found that PD patients without personality disorders had higher HA scores than control subjects, whereas significant differences were not demonstrated for the novelty seeking and reward dependence dimensions.

CONCLUSION

Our results indicate that repeated demonstrations of elevated HA scores in patients with PD are not crucially influenced by comorbid personality disorders.

Temperamental commonalities and differences in euthymic mood disorder patients, creative controls, and healthy controls

OBJECTIVE

Understanding of mood disorders can be enhanced through assessment of temperamental traits. We explored temperamental commonalities and differences among euthymic bipolar (BP) and unipolar (MDD) mood disorder patients, creative discipline graduate student controls (CC), and healthy controls (HC).

METHODS

Forty-nine BP, 25 MDD, 32 CC, and 47 HC completed self-report temperament/personality measures including: The Affective Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A); the Revised NEO Personality Inventory (NEO-PI-R); and the Temperament and Character Inventory (TCI).

RESULTS

Euthymic BP, MDD, and CC, compared to HC, had significantly increased cyclothymia, dysthymia and irritability scores on TEMPS-A; increased neuroticism and decreased conscientiousness on NEO-PI-R; and increased harm avoidance and novelty seeking as well as decreased self-directedness on TCI. TEMPS-A cyclothymia scores were significantly higher in BP than in MDD. NEO-PI-R openness was increased in BP and CC, compared to HC, and in CC compared to MDD. TCI self-transcendence scores in BP were significantly higher than in MDD, CC, and HC.

LIMITATIONS

Most of the subjects were not professional artists, and represented many fields; temperament might be different in different art fields.

CONCLUSIONS

Euthymic BP, MDD, and CC compared to HC, had prominent temperamental commonalities. However, BP and CC had the additional commonality of increased openness compared to HC. BP had particularly high Cyclothymia scores that were significantly higher then those of MDD. The prominent BP-CC overlap suggests underlying neurobiological commonalities between people with mood disorders and individuals involved in creative disciplines, consistent with the notion of a temperamental contribution to enhanced creativity in individuals with bipolar disorders.

Comorbid personality disorders in subjects with panic disorder: do personality disorders increase clinical severity?

Personality disorders are common in subjects with panic disorder. Personality disorders have been shown to affect the course of panic disorder. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder. This study included 122 adults (71 women, 41 men) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for panic disorder (with or without agoraphobia). Clinical assessment was conducted by using the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and the Panic and Agoraphobia Scale, Global Assessment Functioning Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Patients who had a history of sexual abuse were assessed with Sexual Abuse Severity Scale. Logistic regressions were used to identify predictors of suicide attempts, suicidal ideation, sexual abuse, and early onset of disorder. The rates of comorbid Axes I and II psychiatric disorders were 80.3% and 33.9%, respectively, in patients with panic disorder. Patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning. The rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. The rate of patients with panic disorder and a history of childhood sexual abuse was 12.5%. The predictor of sexual abuse was borderline personality disorder. The predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects with panic disorder. In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.

Personality characterizations of outpatients with schizophrenia, schizophrenia with substance abuse, and primary substance abuse

The study extended previous research on the relationship between personality traits and Axis I disorders. It examined personality differences between individuals diagnosed with schizophrenia and substance abuse and also included individuals dually diagnosed with both schizophrenia and substance abuse. Comparisons were made with respect to characteristics of both normal personality, as measured by the NEO Five-Factor Inventory (NEO-FFI), and disordered personality, as measured by the Millon Multiaxial Personality Inventory. On the NEO-FFI, all groups differed significantly from the NEO-FFI normative sample on at least three personality domains. As predicted, the dual diagnosis group showed the most personality deviance and pathology. The schizophrenia group was primarily distinguished by higher levels of agreeableness, whereas the substance abuse group was more extroverted and showed a prominence of Cluster B personality patterns. An unexpected finding was an interaction between diagnostic group and age, such that older relative to younger individuals in the single diagnosis groups showed greater personality adaptivity and moderation, whereas older individuals in the dual diagnosis group showed less.

Sex hormones and biogenic amine turnover of sex offenders in relation to their temperament and character dimensions

Relationships between Cloninger's temperament and character dimensions and plasma sex hormone levels and biogenic amine turnover were studied in male prison inmates convicted of rape (n=61) or child molestation (n=24) and normal male controls (n=25). The participants completed the Temperament and Character Inventory (TCI), which includes the temperament dimensions Novelty Seeking, Harm Avoidance, Reward Dependence and Persistence as well as the character dimensions Self-Directedness, Cooperativeness and Self-Transcendence. Plasma levels of testosterone, dihydrotestosterone, sex hormone binding globulin, luteinizing hormone (LH) and follicle-stimulating hormone were estimated in plasma samples and 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid (HVA), and 3-methoxy-4-hydroxyphenylglycol (MHPG) in urine samples. Both sex offender groups had higher Novelty, Seeking and lower Reward Dependence, Self-Directedness and Cooperativeness scores compared with the controls. Plasma levels of testosterone and dihydrotestosterone were significantly higher in rapists than in controls. Novelty Seeking scores were positively correlated with LH levels in rapists, and with testosterone levels in child molesters. Harm Avoidance scores were negatively correlated with 5-HIAA levels in rapists and with HVA levels in child molesters. In rapists, the calculated free androgen index showed a negative correlation with 5-HIAA. For the sex offender sample as a whole, the subgroup with high testosterone levels had higher Harm Avoidance scores, the subgroup with low HVA levels had lower Cooperativeness scores, and the subgroups with high 5HIAA or MHPG levels had lower Persistence scores. The results indicate that Novelty Seeking behavior in the group of rapists is associated with a hyperactive hypothalamic-pituitary-gonadal axis. In addition, low serotonin turnover and low dopamine turnover seem to be associated with a passive-avoidant behavioral style in rapists and child molesters, respectively.

Personality disorder comorbidity in panic disorder patients with or without current major depression

To investigate the relationship between current or past major depressive disorder (MDD) on comorbid personality disorders in patients with panic disorder, we compared the comorbidity of personality disorders using the Structured Clinical Interview for DSM-III-R personality disorders (SCID-II) in 34 panic disorder patients with current MDD (current-MD group), 21 with a history of MDD but not current MDD (past-MD group), and 32 without lifetime MDD comorbidity (non-MD group). With regard to personality disorders, patients in the current-MD group met criteria for at least one personality disorder significantly more often than patients in the past-MD group or the non-MD group (82.4% vs. 52.4% and 56.3%, respectively). The current-MD group showed statistically significantly more borderline, dependent, and obsessive-compulsive personality disorders than the past-MD group or non-MD group. With stepwise regression analyses, number of MDD episodes emerged as an indicator of the comorbidity of cluster C personality disorder and any personality disorders. Future studies should determine whether aggressive treatment of comorbid personality disorders improves the outcome (e.g., lowers the likelihood of comorbid MDD) of patients with panic disorder.

Relationship between perfectionism, personality disorders and agoraphobia in patients with panic disorder

OBJECTIVE

In earlier reports, we found that perfectionism might be involved in the development and/or maintenance of agoraphobia in panic disorder. The present report extends this work by examining the relationship between perfectionism and comorbidity with personality disorders in panic disorder patients with agoraphobia (PDA) and those without agoraphobia (PD).

METHOD

We examined comorbidity of personality disorders by Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and assessed perfectionism using multidimensional perfectionism scale in 56 PDA and 42 PD patients.

RESULTS

The PDA group met criteria for at least one personality disorder significantly more often than the PD group. With stepwise regression analyses, avoidant and obsessive-compulsive personality disorders emerged as significant indicators of perfectionism in patients with panic disorder.

CONCLUSION

These findings suggest that perfectionism in panic disorder patients may be more common in those with comorbid personality disorders, and may be an important target for preventive and therapeutic efforts.

Evaluating the state dependency of the Temperament and Character Inventory dimensions in patients with major depression: a methodological contribution

BACKGROUND

Little is known as to whether or not the seven personality dimensions of Cloninger's theory, particularly the three character dimensions newly included in the theory, are independent of the states of depression.

METHODS

One hundred and eight patients with major depression filled out the Temperament and Character Inventory (TCI) before and after a 16-week antidepressant treatment.

RESULTS

The level of depression, as assessed by the Hamilton Rating Scale for Depression, was correlated positively to the harm avoidance score and negatively to the self-directedness and cooperativeness scores. During the treatment, the scores on these three dimensions significantly changed toward normal values in treatment-responders, but were stable in treatment-nonresponders. The changes in these dimensions were significantly explained by the change in the depression severity during treatment. Scores on novelty seeking, reward dependence, persistence, and self-transcendence were not correlated significantly to the level of depression and did not change significantly during the treatment in either treatment-responders or nonresponders.

LIMITATIONS

The changes in the TCI scores during treatment in this study may reflect a non-specific tendency for the scores to change on retest.

CONCLUSIONS

The results suggest that a depressive state can significantly affect assessments of harm avoidance, self-directedness, and cooperativeness in major depression. The administration of the TCI during a depressive episode may elevate the HA score, and may lower the SD and C scores. These findings highlight the importance of considering the state of depression before drawing conclusions about the TCI personality traits, when a patient with major depression is still experiencing a depressive episode.

Personality dimensions in social phobics with or without depression

OBJECTIVE

This study investigated the personality traits of social phobics using the Temperament and Character Inventory (TCI).

METHOD

A sample of 178 social phobics was assessed with the TCI, and compared with controls. The patients were classified into two groups, according to the absence (SP group) or to the presence (SP+D group) of depression.

RESULTS

We found significant elevated scores for harm avoidance (HA) in social phobics when compared with controls (16.2 +/- 2.7), in both the SP (26.2 +/- 3.5), and the SP+D (28.9 +/- 4.7), groups. Lower self-directedness scores were found in the SP and in the SP+D groups when compared with the controls. Patients with the generalized type of social phobia had higher HA scores as compared with other social phobics.

CONCLUSION

The personality profile obtained in these social phobics, whatever their depressive symptomatology, reflects a dramatically anxious and avoidant temperament associated to an immature character.

Neuroendocrine correlates of temperament traits in abstinent opiate addicts

PURPOSE

Studies investigating temperament traits of drug abusers and their biological correlates have disclosed high rates of novelty seeking (NS) in opiate addicts, possibly based on dysfunctions of the dopaminergic (DA) system. The aims of the present study were to see whether or not the monoamine functions were impaired in detoxified addicts and whether or not these alterations were correlated with temperament traits, given the possibility that impairment of the biological and temperament parameters might be responsible for the development of addiction.

METHODS

We have investigated the DA, serotonergic (5-HT), and noradrenergic (NE) functions in 22 abstinent heroin addicts and 22 healthy controls by challenging the monoamine systems with the DA agonist bromocriptine (brom), the 5-HT agonist D-fenfluramine (D-fen), and the NE agonist clonidine (clon), respectively. We examined the temperament traits by measuring NS, harm avoidance (HA), and reward dependence (RD) using the "Three-Dimensional Personality Questionnaire" (TPQ).

RESULTS

Addicts showed higher than normal NS scores at TPQ blunted 5-HT function, and normal DA and NE activities, in response to the neuroendocrine challenges. NS correlated negatively with the DA function in both addicts and controls, and negatively with the 5-HT function only in addicts. HA correlated positively with 5-HT function in controls but not in addicts.

IMPLICATIONS

The impairment in 5-HT function observed in heroin addicts and the changes in the biological correlates of temperamental traits could increase the proneness to addiction and possible comorbid psychiatric disorders.

Gender-related differences in the onset of panic disorder

OBJECTIVE

To investigate gender-related differences in premorbid conditions and in the role of triggering events in the onset of panic disorder (PD).

METHOD

One hundred and eighty-four out-patients with a principal diagnosis of PD (DSM-IV) were evaluated with a semi-structured interview to generate Axis I and Axis II diagnoses according to DSM-IV, to collect family history of psychiatric disorders and life events. The statistical analysis was performed comparing men and women.

RESULTS

Men and women showed similar age at onset of PD. A family history of mood disorders characterized females. Men had higher rates of cyclothymia, body dysmorphic disorder and depersonalization disorder preceding PD, while women had higher rates of bulimia nervosa. Dependent and histrionic PDs were more common among women, while borderline and schizoid PDs were more common among men. Life events showed a significant role in precipitating PD onset in women.

CONCLUSION

Premorbid clinical conditions of PD seem to differentiate between males and females in the role of precipitating events.

Neuroendocrine correlates of temperamental traits in humans

Studies investigating temperament traits in humans and their biological correlates have found high levels of novelty seeking (NS) linked with dopaminergic system changes, and particularly a deficit of dopamine transporter. Harm avoidance and reward dependence, on the other hand, appeared to be associated, respectively with serotonin and noradrenaline changes. In the present study, we have investigated the dopaminergic (DA), serotonergic (5-HT), and noradrenergic (NE) functions in healthy volunteers by challenging the monoamine systems with the DA agonist bromocriptine, the 5-HT agonist D-fenfluramine, and the NE agonist clonidine, respectively. Parallel to this investigation, we examined the temperament traits of our subjects by measuring NS, harm avoidance (HA) and reward dependence (RD) using the 'Three-dimensional Personality Questionnaire' (TPQ). The aims of the study were to see whether or not the monoamine functions were correlated with temperament traits. Bromocriptine challenge induced a significant GH increase and a significant suppression of PRL. D-fenfluramine test significantly increased PRL and cortisol plasma levels and Clonidine test induced a significant rise in GH values. NS scores showed a significant direct correlation with brom-stimulated GH values (r=0.426, P<0.05) and a significant inverse correlation with brom-inhibited PRL values (r=-0.498, P<0.01). HA scores correlated significantly with D-fen-stimulated PRL and CORT AUCs, (PRL: r=0.424, P<0.05; CORT: r=0. 595, P<0.005). RD scores correlated positively with clon-stimulated GH values (r=0.55; F=8.6; P<0.01) and negatively with brom-inhibited-PRL AUCs (r=-0.439, P<0.05). Our data support Cloninger theory concerning the biological correlates of temperamental traits, and evidence the link between the neuroendocrine responses to dynamic challenges and stable temperament features.

Normative data and factor structure of the Temperament and Character Inventory (TCI) in the French version

We explored the psychometric features of the French Temperament and Character Inventory (TCI) in a 602-subject community sample (263 men and 339 women), representative of the French population. The factor structures of the temperament and character dimensions, explored separately, were in agreement with the hypothesized constructs, except for the scales Novelty Seeking NS1 (exploratory excitability), Persistence, and Self-Directedness SD4 (self-acceptance). The internal consistency of the main dimensions was good (Cronbach alpha coefficients between 0.68 and 0.82), but weak for Persistence (0.49). The mean scores of the temperament dimensions were notably different from those published in other normative data - especially lower for Novelty Seeking (16.4+/-5.6) and higher for Harm Avoidance (16.1+/-7.2) when compared with US data - suggesting cross-cultural differences in personality assessment, and the necessity to use specific normative values with each translated instrument.

Temperament and personality features in patients with major depression, panic disorder and mixed conditions

METHOD

Forty-two patients with Panic Disorder (P), 18 with Major Depression (MD), 35 with both conditions (MIX) and 45 healthy subjects (C) were tested with the Tridimensional Personality Questionnaire and the Structured Interview for DSM-III-R Personality Disorders.

RESULTS

A different prevalence of Dependent (P = 16.7%, MD = 5.6%, MIX = 41.4%, C = 2.1%) (P < 0.001), Obsessive-Compulsive (P = 4.8%, MD = 27.8%, MIX = 3.4%, C = 0%) (P < 0.001) and Histrionic (P =23.8%, MD = 0%, MIX = 31%, C = 4.2%) (P = 0.001) personality disorders (PD) was found among groups. Harm Avoidance (HA) (P < 0.001) and Reward Dependence (RD) (P <0.001) were higher in patients than in controls. As expected the patients with comorbid conditions (MIX) showed higher HA levels (P < 0.01) and a greater prevalence of PDs, particularly of Cluster C compared to patients with pure disorders.

CONCLUSIONS

This study suggests that high HA and RD scores are associated with P, MD and MIX, and the former dimension is even higher in MIX patients.

Prevalence, patterns and role of personality disorders in panic disorder patients with and without comorbid (lifetime) major depression

A total of 84 consecutive out-patients from the Anxiety Disorders Clinic of the Psychiatric University Hospital in Graz with a current panic disorder were diagnosed for Axis I and II disorders using the Structured Clinical Interviews for DSM-III-R. The subjects were divided into two groups: (i) 49 patients who met the criteria for panic disorder with or without agoraphobia and had no history of an affective disorder and (ii) 35 patients who had a (lifetime) comorbidity of a major depressive disorder. There was a statistically significant difference in the prevalence of personality disorders between the two groups, which was due to the higher frequency of narcissistic personality disorder in the comorbid sample. Logistic regression analysis revealed that agoraphobia and/or major depression were associated with personality disorders, thus indicating that the relationship between panic disorder, agoraphobia and major depression is not straightforward, but is strongly influenced by the presence of Axis II disorders. Furthermore, the results of this study provide support for the 'unitary position' concerning the relationship between panic disorder and depression.