Temperament and character in patients with borderline personality disorder taking gender and comorbidity into account

This study examined correlations of borderline personality disorder (BPD) symptoms with scales from Cloninger's psychobiological model taking gender and psychiatric comorbidity into consideration. Inpatients with BPD (n = 202) were compared to several control groups including psychiatrically healthy persons (n = 327), subjects with affective disorders (n = 46), alcohol use disorders (n = 47), cluster C personality disorders (n = 23) and antisocial personality disorder (n = 25). The results indicate that only males with BPD presented an 'explosive' temperament suggested by Cloninger, with simultaneously high levels of novelty seeking and harm avoidance. In contrast, women with BPD were characterized by high levels of harm avoidance, but not novelty seeking. Regarding temperament and character dimensions our analyses suggest that patients with BPD could be characterized, in particular, by a combination of high harm avoidance and very low self-directedness. The specific temperament configuration of BPD postulated by Cloninger's psychobiological model could only partially be supported. The results provide support for the importance of controlling for gender effects when investigating the applicability of dimensional models with respect to personality disorders.     

Correlations between trait anxiety, personality and fatigue: study based on the Temperament and Character Inventory

OBJECTIVE: In our study, we explored the associations among anxiety, the dimensions of Cloninger's theoretically based and empirically validated psychobiological model of personality (Temperament and Character Inventory, TCI) and fatigue in order to clarify the personality risk factors for fatigue. METHODS: Fifth-year students (n=89) and freshmen (n=162) at Saga Medical School and psychiatric outpatients of Saga Medical School Hospital (n=101) were investigated with the State-Trait Anxiety Inventory (STAI, Japanese version), the TCI (Japanese version), the General Health Questionnaire (GHQ-30) and the self-rating Fatigue Symptom Checklist (FSC), which describe fatigue along three subscales (general, physical and psychological fatigue). Correlation and ANOVA analyses were performed in this study. RESULTS: The analysis identified a significant relation (P<.0005) between trait anxiety and fatigue. The TCI dimension of harm avoidance (HA) is positively correlated with both trait anxiety and fatigue (general fatigue, psychological fatigue and physical fatigue). The character dimension of self-directedness is negatively correlated with both trait anxiety and fatigue. CONCLUSIONS: There is an inherent relationship among trait anxiety, the temperament dimension of harm avoidance, character dimension of self-directedness and fatigue. The TCI dimensions, harm avoidance and self-directedness, might be considered as predictors for fatigue-related disorders.     

Cloninger's temperament dimensions and affective responses to different challenges

Cloninger's psychobiological model of temperament and character postulates that each of the temperament dimensions is associated with a specific emotional experience, depending on the situational cues. The aim of the present study was to test this postulate in a variety of challenging experimental tasks. The participants were 91 healthy young adults whose temperament was assessed with the temperament and character inventory. The subjects rated their emotions during each task and rest period using an adjective checklist. Novelty seeking was associated with dullness during monotonous and aversive situations and with a higher level of pleasantness during the initial baseline period and the appetitive situation. Harm avoidance was associated with higher levels of fear and unpleasant emotions and lower levels of positively valenced emotions. The present study provides support for the validity of Cloninger's temperament dimensions as predictors of emotional responses during different challenges. Especially, novelty seeking and harm avoidance appear to have a significant influence on emotional experience.     

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

Context

Although psychiatric research uses clear diagnostic criteria to describe bipolar disorders, therapists in clinical practice are often confronted with patients presenting a number of symptoms with different degrees of intensity and belonging to more than one diagnostic category. With respect to this actual clinical complexity, there is an increasing interest in a dimensional approach of psychopathological traits to gain better understanding of mental disorders. In the 1980s, Robert Cloninger elaborated on a psychobiological model to explain personality in clinical groups as well as in general population. His model was then operationalised with a questionnaire evaluating temperament (harm avoidance, novelty seeking, reward dependence and persistence) and character (self-directeness, cooperativeness, self-transcendence): the Temperament and Character Inventory (TCI).

Objective

To review all studies conducted in adult bipolar samples on temperament and character according to Cloninger's psychobiological model.

Materials and methods

A search was conducted on MedLine and PsycInfo for all articles written in English or French, between 1986 and September 2008, on temperament and character in bipolar disorder. The words bipolar disorder or mania had to be associated with the following keywords temperament, TCI, Cloninger, TPQ, harm avoidance, novelty seeking, reward dependence.

Results

Across studies, compared to the general population, bipolar subjects have significantly higher harm avoidance, higher novelty seeking and lower self-directness. Some studies have investigated differences between bipolar disorders and other psychopathologies like depression, and borderline personality disorder. Among studies on depression and bipolar disorder, there is no consensus on the findings. Compared to borderline personality disorder patients, bipolar disorder subjects have lower harm avoidance and higher self-directness and cooperativeness. This finding is consistent with Cloninger's hypothesis that all personality disorders have lower self-directness than any axis I disorder. With respect to other temperament and character traits, studies yielded results either contradictory or non-significant. No difference was found when the bipolar group was subdivided according to the clinical presentation (type I vs II) and the suicidal risk, apart from harm avoidance. Bipolar subjects with substance related disorders displayed higher novelty seeking and lower persistence, which might be explained by a low dopaminergic activity that had to be compensated with drug intake. Low persistence causes greater difficulties to overcome substance dependence. However, it is not possible to determine whether these temperament characteristics are specifically linked to bipolar disorder, substance related disorders, or both. Similar limitations apply to bipolar patients with comorbid anxiety disorders, who presented higher harm avoidance and lower self-directness.

Conclusions

Across studies, there are limitations which impede the generalization of the findings to other clinical populations. Age, gender, cultural characteristics, mood status during evaluation, group size, versions of the TCI questionnaire, suicidal risk, clinical type (BP I vs II) and comorbidity differ from one study to another. These methodological variables should be controlled in future studies. Nevertheless, adult bipolar patients appear to present a different temperamental profile than other clinical groups and general population. Therefore, Cloninger's psychobiological model of temperament remains an interesting avenue for future researches in bipolar disorder.     

Do the dimensions of the temperament and character inventory map a simple genetic architecture? Evidence from molecular genetics and factor analysis

OBJECTIVE: It has been reported that the human temperament dimensions of novelty seeking and harm avoidance are associated with polymorphisms in the D(4) dopamine receptor gene (D4DR) and the serotonin-transporter-linked promoter region (5-HTTLPR), respectively. Although these findings are consistent with Cloninger's hypothesized psychobiological model of temperament and character, many studies failed to replicate these findings. In the present study the authors tested whether the psychobiological model taps the genetic architecture of personality by exploring associations between these candidate genes and the dimensions of the Temperament and Character Inventory and by examining its phenotypic structure. METHOD: Of the 946 male and female participants in the Baltimore Longitudinal Study of Aging to whom the Temperament and Character Inventory was administered, 587 were genotyped for a polymorphism with a 48-base-pair repeat in the D4DR gene and 425 were genotyped for a 44-base-pair insertion or deletion in the 5-HTTLPR polymorphism. RESULTS: There was no significant association between D4DR polymorphisms and novelty seeking. The authors also failed to find an association between 5-HTTLPR polymorphisms and harm avoidance. The factor structure of the Temperament and Character Inventory did not reveal the hypothesized phenotypic structure. CONCLUSIONS: This investigation produced no support for the temperament-character model at either the biological or psychological level.     

Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders

OBJECTIVE: To evaluate childhood experiences (neglect and abuse), temperament and childhood and adolescent psychopathology as risk factors for avoidant and borderline personality disorders in depressed outpatients. METHOD: One hundred and eighty depressed outpatients were evaluated for personality disorders. Risk factors of childhood abuse, parental care, temperament, conduct disorder symptoms, childhood and adolescent anxiety disorders, depressive episodes, hypomania and alcohol and drug dependence were obtained by questionnaires and interviews. RESULTS: Avoidant personality disorder can be conceptualized as arising from a combination of high harm avoidance (shy, anxious), childhood and adolescent anxiety disorders and parental neglect. Borderline personality disorder can be formulated as arising from a combination of childhood abuse and/or neglect, a borderline temperament (high novelty seeking and high harm avoidance), and childhood and adolescent depression, hypomania, conduct disorder and alcohol and drug dependence. CONCLUSIONS: Combinations of risk factors from the three domains of temperament, childhood experiences and childhood and adolescent psychopathology make major contributions to the development of avoidant and borderline personality disorders.     

Alexithymia and temperament and character model of personality in alcohol-dependent Turkish men

Aims:  Alexithymia, a personality trait characterized as having problems identifying, describing, and working with one's own feelings, often marked by a lack of understanding of the feelings of others, is only partly described within the context of personality. The aim of the present study was therefore to study the prevalence of alexithymia among male alcohol-dependent inpatients and investigate the relationship between alexithymia and the dimensions of Cloninger's psychobiological model of personality.
Methods:  The Turkish version of the Toronto Alexithymia Scale (TAS-20) and the Turkish version of the Temperament and Character Inventory (TCI) were administered to 111 male alcohol-dependent inpatients.
Results:  TAS-20 scores correlated positively with harm avoidance and self-transcendence and negatively with self-directedness and cooperativeness. Regression analysis identified high harm avoidance and self-transcendence and low self-directedness as independent predictors of alexithymia. Also harm avoidance and self-transcendence predicted alexithymia in a logistic regression model.
Conclusions:  Alexithymia can be explained by specific dimensions within Cloninger's psychobiological model of personality in alcohol-dependent Turkish men.     

Relation entre la motivation au changement et les dimensions du Temperament and Character Inventory (TCI) de Cloninger chez des patients alcoolodépendants, dépressifs et anxieux sociaux

Practicing cognitive and behavioral therapy, one often observes a lack of readiness to change. This study seeks to identify factors tied to this lack of motivation: Dependence itself, temperament and character profile, affective disorders? How improve alcoholics’ inpatients readiness to change who have depressive and social anxiety disorders associated? To this end, we compared 12 separated alcoholics’ inpatients, with two other groups having a major depressive state or a social anxiety. We used a motivational interviewing guide built from the Prochaska and Di Clemente model, hetero- and autoquestionnaires, and the TCI. These three groups have the same depressive suffering and high scores of harm avoidance. The “non-ready” to change participants were distinguished from the “decided” ones by scoring different on two-character dimension of the TCI (self-directedness and transcendence). This study applies the model of readiness to change to others disorders than addictions.     

A meta-analysis of temperament in axis I psychiatric disorders

This article reports on a meta-analysis of Cloninger's temperament dimensions (novelty seeking, harm avoidance, reward dependence, and persistence) in individuals with lifetime psychiatric disorders compared with controls and on interdisorder comparisons between these disorders. Nine disorders from 75 studies were included in the meta-analyses. The most consistent feature was elevated harm avoidance: compared with the controls, harm avoidance was higher in all diagnostic groups studied except for those with alcohol use disorders. The increase in effect sizes in harm avoidance scores varied from a very large (d = 2.66) in social phobia to a small effect (effect size, d = 0.29) in alcohol use disorders. In other dimensions, differences between cases and controls were relatively small. However, in pairwise comparisons, notable differences also in other dimensions emerged: in novelty seeking, the lowest scores were in social phobia (d = -0.87) and the highest in bulimia nervosa (d = 0.33); in reward dependence, the lowest scores were in schizophrenia (d = -0.36) and the highest in social phobia (d = 0.12); and in persistence, the lowest scores were in social phobia (d = -0.30) and the highest in anorexia nervosa (d = 0.49). The provided data should be taken into account in the future studies on suggestive vulnerability markers for psychiatric morbidity.     

Temperament and character dimensions and their relationship to major depression and panic disorder

IntroductionSince the first publication of Cloninger's psychobiological model of personality, the relationship between temperament and character dimensions and psychiatric disorders has been widely studied. The exact nature of this interaction, however, is still unclear. Different models have been proposed (state-dependency, vulnerability, continuous spectrum etc).ObjectiveTo analyze the relationship between temperament and character dimensions with depression and panic disorder.MethodSystematic review on interventional studies published up until December 2011 on MEDLINE and ISI databases. Also, a brief review on genetic studies is hereby undertaken, aiming to discuss the gene-environment interaction in relation to this topic.Results:Thirteen studies were included: 10 related to depression and 3 to panic disorder (or unspecific anxiety symptoms). All of them showed association between high harm avoidance (HA) and low self-directedness (SD) with depression and anxiety symptoms. Longitudinal studies demonstrated that these traits may not be just state-dependent.Conclusions:HA and SD dimensions are associated with both the occurrence of depressive and anxiety symptoms. There is also some evidence to suggest that high HA and low SD indicates susceptibility to depression. Longitudinal studies are not sufficient to affirm the same about panic disorder up to the present moment.     

Personality disorder diagnosis by means of the Temperament and Character Inventory

Personality disorders (PDs) criteria are still in development. Cloninger's biosocial theory of personality contributed to this discussion. The aim of the study was to explore the relationships between extreme expressions on temperament and an immature character according to Cloninger's assumptions. Eight hundred healthy volunteers and 200 psychiatric inpatients were consecutively recruited each from Sweden and Germany, and were asked to complete the Temperament and Character Inventory, which measures 4 temperament and 3 character dimensions. Patients differed from controls on temperament and character dimensions. The combination of low and very low character scores with extreme scores in either novelty seeking, harm avoidance, or reward dependence was found more often among patients with PD compared with patients without PD and controls; this is more pronounced with an increasing number of extreme temperament scores. The Temperament and Character Inventory represents a useful tool in the diagnostic process of personality disorders.     

Are there temperament differences between major depression and dysthymic disorder in adolescent clinical outpatients?

AimsThe aim of the study was to explore possible differences in temperament and character dimensions between 2 monodiagnostic adolescent groups of depression, namely, one with a present episode of major depression and subjects with the other being their dysthymic peers.SampleFrom a multisite Western Hungarian sample of consecutively referred 14- to 18-year-old new psychiatric adolescent outpatients, 2 groups were compared: group I, n = 56 (9 males, 47 females), with major depressive disorder (MDD) and group II, n = 27 (6 males, 21 females), with a diagnosis of dysthymic disorder (DD). All other comorbid diagnoses including bipolar and double depression (MDD + DD) cases were excluded. Present suicide events, if the attempter had an underlying diagnosis of depression, were not causes for exclusion. Assessment methods used were the adapted Hungarian versions of the Mini International Neuropsychiatric Interview and the Junior Temperament (Cloninger) Character Inventory.ResultsThe only difference between the major depressive and dysthymic adolescents was harm avoidance, adolescents with major depression having a higher level practice of harm avoidance, whereas the temperament type of MDD vs DD seems to differ only in the aspect of avoiding painful stress. Expectations regarding a worse degree of self-directedness and lower levels of persistence and cooperativeness in the MDD sample were not proved.ConclusionsNo essential temperament differences were found between the 2 adolescent depressive groups. Scarce differences between temperament qualities of MDD and DD may support Akiskal's continuum theory of depressive disorders. More research and the use of closer clinical personality typologies are warranted to explore possible personality trait differences (if they exist) between clinical diagnostic groups of adolescent patients.     

Temperament and character in primary insomnia.

Recent studies by Cloninger suggest that the temperament dimension of harm avoidance might be related to serotonergic activity. Since serotonergic mechanisms equally play a major role in sleep regulation, we decided to use Cloninger's psychobiological model of temperament and character to assess whether there is a link between psychophysiologic insomnia and specific personality traits. Chronic insomnia is a common complaint in modern society, and it is still controversial whether insomniacs share specific personality traits. Thirty-two chronic insomniacs (< 50 years) were studied. They underwent polysomnography for two consecutive nights and filled out the 226-item self-questionnaire of Temperament and Character Inventory as well as the Hospital Anxiety and Depression scale. (1) Harm avoidance for all subscores was significantly higher in insomniac patients when compared with controls; (2) self-directedness scores were lower in insomniacs; (3) sleep latency was positively correlated to harm avoidance; (4) HA1 (anticipatory worry) was negatively correlated to REM latency. Temperament and Character Inventory is a useful tool in the investigation of chronic insomnia. Serotonergic mechanisms might explain the high incidence of harm avoidance as personality trait in psychophysiologic insomniac patients. Further studies are needed to see whether harm avoidance could be a psychological vulnerability marker for primary insomnia and be used as predictor of SSRI treatment responders.     

Sex differences in Cloninger's temperament dimensions--a meta-analysis

There have been many comparisons between men and women on psychological characteristics and personality. The Tridimensional Personality Questionnaire and Temperament and Character Inventory developed by Cloninger are used to measure the following temperament dimensions: novelty seeking, harm avoidance, reward dependence, and persistence. Studies using these scales in healthy (nonclinical) populations have reported varying results on sex differences, but there is no meta-analysis of the topic. In this study, meta-analytic methods were used to estimate sex differences in these temperament dimensions and to study the effect of mean age of the sample and location of the study (Asia/other) on possible differences. Studies on healthy populations were systematically collected; the required minimum sample size was 100. The search resulted in 32 eligible studies. Consequently, women scored higher in reward dependence (pooled effect size; Cohen's d = -0.63; z test, P value < .001) and harm avoidance (d = -0.33; P < .001). There were no differences in novelty seeking (d = -0.04; P = .29) or in persistence (d = -0.02; P = .62). The sex difference in reward dependence was significantly smaller in Asian studies. This study was the first one to pool studies on sex differences in Cloninger's temperament dimensions. Women scored consistently higher in harm avoidance in the studies included. Together with similar sex difference found in related traits (eg, depression), this finding supports the validity of this temperament dimension. The given data on sex differences should be taken into account in future studies using these instruments.     

Temperament and character inventory (TCI) and depression

Although several studies have assessed the relationships between the temperament dimensions of the Cloninger model of personality and depression, little is known about the role played by the character dimensions proposed by the seven-factor model of Cloninger in depression. In this study, the relationships between the Temperament and Character Inventory (TCI) and depression were examined in a sample of 40 major depressive patients and 40 healthy controls. Depressed patients exhibit higher harm avoidance and self-transcendence scores as well as lower self-directedness and cooperativeness scores as compared to healthy controls. However, the three other dimensions do not differ between depressive patients and controls. Among the depressive group, harm avoidance, self-directedness and cooperativeness dimensions are related to the severity of depression as assessed by the Hamilton scale. This study confirms the state dependence of the harm avoidance dimension and suggests a relationship between the character dimensions of the Cloninger model and depression.     

Interrelations between temperament, character, and parental rearing among delinquent adolescents: a cross-validation

We performed a cross-validation of results from investigations in juvenile delinquents in Russia and Germany concerning relationships of personality characteristics in terms of temperament and character with parental rearing. Both studies used the Temperament and Character Inventory (TCI) based on Cloninger's psychobiological theory, and the Own Memories on Parenting (Egna Minnen Betr?ffande Uppfostran-Swedish [EMBU]) questionnaire on parental rearing based on Perris' vulnerability model. The inter-relatedness of parental rearing, temperament, and character traits in socially normally integrated adolescents, as well as in delinquent adolescents, implying direct and indirect pathways from personality and parental rearing to delinquency, could be cross-validated. Differences between delinquents and socially normally integrated adolescents are rather based on different levels of expressions of various temperament traits, harm avoidance and novelty seeking in particular, and the character trait self-directedness, as well as on parental rearing behavior (predominantly parental rejection and emotional warmth) than on different structures within related developmental processes.     

Temperament and character dimensions in bipolar I disorder: a comparison to healthy controls

Research on phenotypic markers of vulnerability to bipolar disorder has focused on the identification of personality traits uniquely associated with the illness. To expand knowledge in this area, we compared Cloninger's seven temperament and character dimensions in 85 euthymic/subsyndromal bipolar I inpatients and outpatients and 85 age and sex matched community controls. We also examined associations between Cloninger's personality traits and mood state in the patient group. Bipolar subjects were administered the Structured Clinical Interview for DSM-IV (SCID), Hamilton Rating Scale for Depression, and Clinician-Administered Rating Scale for Mania. Controls received the SCID, a family psychiatric history questionnaire, and urine toxicology screen to confirm healthy status. Both groups competed the 240-item Temperament and Character Inventory (TCI). A multivariate analysis of covariance, accounting for demographic factors, was conducted to compare the groups on the TCI. Bipolar I patients scored higher on harm avoidance, lower on self-directedness, and higher on self-transcendence compared to controls. Harm avoidance and self-directedness were correlated with residual depressive symptoms positively and negatively, respectively; persistence was correlated with residual manic symptoms; and selftranscendence was correlated with residual psychotic symptoms in patients. The results indicate that bipolar I subjects do possess personality traits that are significantly different from non-ill individuals. However, only a prospective, longitudinal study may determine whether these traits mark a vulnerability to the disorder, or represent the scarring effect of affective episodes and chronic subsyndromal symptoms.     

Personality dimensions in obsessive-compulsive disorder: relation to clinical variables

Research on the relationship between personality factors and obsessive-compulsive disorder (OCD) has proved difficult to interpret due to conceptual problems including a lack of consensus on the model of personality employed as a framework as well as a failure to consider the clinical heterogeneity of the disorder. The aim of this study was to examine the dimensional personality profile associated with OCD and to determine whether any relationship exists between personality factors and clinical variables in a sample of 60 OCD outpatients who were administered Cloninger's Temperament and Character Inventory (TCI). The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Hamilton Depression Rating Scale (HDRS) and the Y-BOCS symptom checklist were used to assess the severity of obsessive-compulsive and depressive symptoms and the presence of the main OCD symptom dimensions. OCD patients showed significantly higher scores in harm avoidance and lower scores in novelty-seeking, self-directedness and cooperativeness than healthy subjects. These results remained unchanged when only pure OCD patients without comorbid psychiatric conditions were considered. Comorbid depressive symptoms and hoarding obsessions and compulsions were significantly associated with high harm avoidance scores. These results support the existence of a dimensional personality profile associated with OCD and characterized by high harm avoidance and low novelty-seeking, self-directedness and cooperativeness scores, but also emphasize the importance of considering the influence of comorbid clinical conditions or symptom subtypes in addressing the role of personality factors in OCD.     

Personality related to coping and social support among Iranian refugees in Sweden

The aim of this study was to investigate the interrelatedness between temperament and character according to Cloninger's biosocial theory of personality, coping behavior, and social support among traumatized refugees. Personality, psychopathological disturbances, coping resources, and social support were assessed in 100 Iranian refugees resettled in Sweden who had been exposed to various extreme traumatic life events in Iran before their escape. Individuals traumatized by war experiences as soldiers, with low Beck Depression Inventory scores showed the lowest scores in Harm Avoidance and the highest in Self-Directedness and Cooperativeness. Concerning coping resources and social support, these subjects scored slightly higher and the traumatized refugees with high Beck Depression Inventory scores scored slightly lower compared with nontraumatized subjects. Resilient refugees are characterized by low harm avoidance, high self-directedness, and high cooperativeness scores which enables them to develop effective coping strategies to obtain sufficient social support and thus to become more resistant against severe trauma.     

Normative data and factorial structure of the Turkish version of the Temperament and Character Inventory

Cloninger's dimensional psychobiological model of personality accounts for both normal and abnormal variation in 2 major personality components: temperament and character. Here, we examined the psychometric properties of the Turkish version of the Temperament and Character Inventory (TCI) in a healthy Turkish population, obtaining normative data for the Turkish TCI. The study was conducted in healthy volunteers at both Karadeniz Technical University School of Medicine and Atatürk University School of Medicine (n = 683). The Turkish sample had significantly lower mean scores on Novelty Seeking and Reward Dependence and higher mean scores on Harm Avoidance than the American sample. The Turkish sample had significantly lower scores on Self-Directedness, Cooperativeness, and Self-Transcendence. Self-Directedness and Harm Avoidance, Cooperativeness and Reward Dependence, and Cooperativeness and Self-Directedness were intercorrelated. The Cronbach coeficients were between 0.60 and 0.85 on temperament dimensions, and between 0.82 and 0.83 on character dimensions. The lowest Cronbach coefficients were found in Reward Dependence (0.60) and Persistence (0.62). A principal axis factor analysis with a 4-factor solution revealed the highest loadings on Novelty Seeking and Harm Avoidance and relatively weaker loadings on Reward Dependence and Persistence. A 3-factor solution for character subscales indicated the highest loadings on Cooperativeness and Self-Transcendence. The factorial structure was consistent with Cloninger's 7-factor model of personality, and test-retest indicated a good stability of scores over time. The reliability and factorial validity of the Turkish version of the TCI are therefore supported.