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

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

Cyclothymic-depressive-anxious temperament pattern is related to suicide risk in 346 patients with major mood disorders

BackgroundSuicidal behavior is one of the most alarming signs not only in psychiatry, and current major depressive episode is the most frequent medical condition among suicide victims and attempters. The aim of the study was to investigate the relationship between the individual pattern of affective temperaments, non-typical symptoms of depression as measured with the Gotland Scale for Male Depression (GSMD), hopelessness and suicidal behavior in major mood disorder patients.MethodsParticipants were 346 adult inpatients (151 men and 195 women) with major mood disorders consecutively admitted to the Department of Psychiatry of the Sant'Andrea University Hospital in Rome, Italy. All the patients were administered the TEMPS-A, the GSMD, and the Beck Hopelessness Scale (BHS) and the Mini International Neuropsychiatric Interview (MINI).ResultsA Two Step Cluster Analysis procedure, performed to reveal natural groupings within patients' response set, indicated that there were 2-groups: a cyclothymic–depressive–anxious group and a hyperthymic group. More than 81% of the patients with prevailing cyclothymic–depressive–anxious temperament had mild to severe suicidal risk on the MINI vs. only around 42% of the patients with prevailing hyperthymic temperament. Sixty-four percent of patients with prevailing cyclothymic–depressive–anxious temperament had BHS scores of 9 or higher versus only 13% of patients with prevailing hyperthymic temperament. Also, patients with prevailing cyclothymic–depressive–anxious temperament more likely had higher GSMD than patients with prevailing hyperthymic temperament.LimitationsThe correlational nature of the study limits causal conclusions to be drawn.ConclusionsOur results indicate that affective temperament measure along with Gotland Scale for Male Depression could be useful tools in screening and identifying those affective disorder patients who are at higher risk of suicidal behavior.     

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

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

Temperamental traits and results of psychoaptitude tests in applicants to become a cadet officer in the Italian Navy

Background

Consistently with the involvement of affective temperaments in professional choices, our research team is aiming to outline the temperamental profile of subjects who are applying to enter a military career in the Italian Armed Forces. In this study we aim to verify the importance of temperamental traits not only in choosing the military career as a profession, but also in passing or failing the entrance examinations.

Methods

We compared the affective temperaments (evaluated by TEMPS-A[P]) of those applying to become a cadet officer in the Italian Navy, divided into various subgroups depending on whether they passed or failed the entrance examination at various levels (high school final test, medical (physical and psychiatric), mathematical examination and aptitude test). We also tested for correlations between grades received and temperamental scores.

Results

Higher scores for those with a hyperthymic and lower scores for those with a depressive, cyclothymic or irritable temperament characterized applicants taking medical exams and aptitude tests. Higher scores on the high school final test correlated with lower hyperthymic, cyclothymic and irritable temperament scores. No correlations were found between temperamental traits and mathematical examinations. Multivariate analysis stressed the negative impact of a cyclothymic temperament and the poor discriminant power of temperaments regarding medical and mathematical examinations, and aptitude tests. Conversely, temperaments showed good discriminant power as far as psychiatric examinations are concerned.

Conclusions

Hyperthymic temperamental traits appear to be important not only in choosing a profession, but also in passing entrance examinations. Even so, affective temperaments (strong hyperthymic and weak cyclothymic, depressive and irritable traits) are the only successfully predictors of the outcome of psychiatric examinations and, to a lesser extent, medical examinations and aptitude tests. Achieving high school graduation and passing mathematical exams are independent of temperamental traits.     

Bipolar disorders and affective temperaments: a national family study testing the "endophenotype" and "subaffective" theses using the TEMPS-A Buenos Aires

BACKGROUND: The purpose of this study is to examine the prevalence of affective temperaments between clinically unaffected relatives of bipolar patients and secondarily to investigate the impact of these "subaffective" forms on their quality of life (QoL). METHODS: The study was performed in seven sites across Argentina. We administered the scales TEMPS-A and Quality of Life Index to a sample of 114 non-ill first degree relatives of bipolar disorder patients ("cases") and 115 comparison subjects without family history of affective illness ("controls"). We used The Mood Disorder Questionnaire to rule out clinical bipolarity. RESULTS: Mean scores on all TEMPS-A subscales were significantly higher in cases, except for hyperthymia. The prevalence of affective temperaments, according to Argentinean cut-off points, was also higher, with statistical significance for cyclothymic and anxious temperaments. Regarding QoL, we found no significant differences between both groups, except for interpersonal functioning, which was better in controls. A detailed subanalysis showed significant effects of QoL domains for all temperaments, except for the hyperthymic. LIMITATIONS: We used self-report measures. A larger sample size would have provided us greater statistical power for certain analyses. CONCLUSIONS: Our findings support the concept of a spectrum of subthreshold affective traits or temperaments - especially for the cyclothymic and anxious - in bipolar pedigrees. We further demonstrated that, except for the hyperthymic, quality of life was affected by these temperaments in "clinically well" relatives. Overall, our data are compatible with the "endophenotype" and "subaffective" theses for affective temperaments.     

Affective Temperaments,Mood, and Insomnia Symptoms in a Nonclinical Sample

Objective: The aim of the study was to understand the relationship between affective temperaments and insomnia symptoms and to examine mood state as a mediator in this relationship. Participants: The sample consisted of 659 adults (428 women and 231 men), aged 18–77 years old, derived from a nonclinical population. Methods: Affective temperaments were assessed using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A). Mood was measured using the UWIST Mood Adjective Checklist (UMACL). Insomnia was evaluated by the Athens Insomnia Scale. Results: We found positive correlations among anxious, cyclothymic, depressive, and irritable affective temperaments and insomnia symptoms. Negative correlation with insomnia symptoms was found for hyperthymic temperament. Energetic arousal and tense arousal, as mood dimensions, positively correlated with insomnia symptoms. Hierarchical regression analysis indicated that anxious, cyclothymic, and hyperthymic temperaments were significant predictors of insomnia symptoms. Mediation analyses indicated that anxious, cyclothymic, and hyperthymic temperaments affected insomnia symptoms, both directly and indirectly, through energetic arousal as a mediator. Conclusions: The results showed a relationship between affective temperaments and insomnia symptoms and included the role of energetic arousal, a mood state dimension, as a mediator.     

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

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

Bipolar II with and without cyclothymic temperament: "dark" and "sunny" expressions of soft bipolarity

BACKGROUND: In the present report deriving from the French national multi-site EPIDEP study, we focus on the characteristics of Bipolar II (BP-II), divided on the basis of cyclothymic temperament (CT). In our companion article (Hantouche et al., this issue), we found that this temperament in its self-rated version correlated significantly with hypomanic behavior of a risk-taking nature. Our aim in the present analyses is to further test the hypothesis that such patients-assigned to CT on the basis of clinical interview-represent a more "unstable" variant of BP-II. METHODS: From a total major depressive population of 537 psychiatric patients, 493 were re-examined on average a month later; after excluding 256 DSM-IV MDD and 41 with history of mania, the remaining 196 were placed in the BP-II spectrum. As mounting international evidence indicates that hypomania associated with antidepressants belongs to this spectrum, such association per se did not constitute a ground for exclusion. CT was assessed by clinicians using a semi-structured interview based on in its French version; as two files did not contain full interview data on CT, the critical clinical variable in the present analyses, this left us with an analysis sample of 194 BP-II. Socio-demographic, psychometric, clinical, familial and historical parameters were compared between BP-II subdivided by CT. Psychometric measures included self-rated CT and hypomania scales, as well as Hamilton and Rosenthal scales for depression. RESULTS: BP-II cases categorically assigned to CT (n=74) versus those without CT (n=120), were differentiated as follows: (1). younger age at onset (P=0.005) and age at seeking help (P=0.05); (2). higher scores on HAM-D (P=0.03) and Rosenthal (atypical depressive) scale (P=0.007); (3). longer delay between onset of illness and recognition of bipolarity (P=0.0002); (4). higher rate of psychiatric comorbidity (P=0.04); (5). different profiles on axis II (i.e., more histrionic, passive-aggressive and less obsessive-compulsive personality disorders). Family history for depressive and bipolar disorders did not significantly distinguish the two groups; however, chronic affective syndromes were significantly higher in BP-II with CT. Finally, cyclothymic BP-II scored significantly much higher on irritable-risk-taking than "classic" driven-euphoric items of hypomania. CONCLUSION: Depressions arising from a cyclothymic temperament-even when meeting full criteria for hypomania-are likely to be misdiagnosed as personality disorders. Their high familial load for affective disorders (including that for bipolar disorder) validate the bipolar nature of these "cyclothymic depressions." Our data support their inclusion as a more "unstable" variant of BP-II, which we have elsewhere termed "BP-II 1/2." These patients can best be characterized as the "darker" expression of the more prototypical "sunny" BP-II phenotype. Coupled with the data from our companion paper (Hantouche et al., 2003, this issue), the present findings indicate that screening for cyclothymia in major depressive patients represents a viable approach for detecting a bipolar subtype that could otherwise be mistaken for an erratic personality disorder. Overall, our findings support recent international consensus in favoring the diagnosis of cyclothymic and bipolar II disorders over erratic and borderline personality disorders when criteria for both sets of disorders are concurrently met.     

The high prevalence of bipolar II and associated cyclothymic and hyperthymic temperaments in HIV-patients

Background: Although recent studies have shown high rates of current and lifetime depression in HIV-infected patients, there is little systematic data on the occurrence of bipolarity in these patients. Method: We compared 46 HIV patients with index major depressive episode (MDE) to an equal number of age- and sex-matched seronegative MDE patients, and systematically examined rates of DSM-III-R bipolar subtypes (enriched in accordance with Akiskal's system of classifying soft bipolar disorders). Results: Although HIV and psychiatric clinic patients had comparable background in terms of familial affective loading, HIV patients had significantly higher familial rates for alcohol and substance use. The more important finding was the significantly higher proportion of HIV patients with lifetime bipolar II disorder (78%), and associated cyclothymic (52%) and hyperthymic (35%) temperaments; the findings were the same irrespective of HIV risk status (intravenous drug user vs. homosexual and other risk groups combined). Limitations: The major methodologic limitation of our study is that clinicians evaluating temperament were not blind to affective diagnoses and family history. The comparison affective group was a sample of convenience drawn from the same tertiary care university facility. Conclusion: The finding of a high rate of bipolar II disorder in HIV patients has treatment implications for seropositive patients presenting with depression. More provocatively, we submit that premorbid impulsive risk-taking traits associated with cyclothymic and hyperthymic temperaments may have played an important role in needle-sharing drug use and/or unprotected sexual behavior, leading ultimately to infection with HIV. Given their public health importance, these clinical findings and insights merit further investigation. In particular, systematic case-control studies, as well as other large scale studies with prospective methodology need to be conducted.     

Affective temperaments are associated with specific clusters of symptoms and psychopathology: A cross-sectional study on bipolar disorder inpatients in acute manic,mixed, or depressive relapse

Background

The aim of this study was to assess whether different affective temperaments could be related to a specific mood disorder diagnosis and/or to different therapeutic choices in inpatients admitted for an acute relapse of their primary mood disorder.

Method

Hundred and twenty-nine inpatients were consecutively assessed by means of the Structured and Clinical Interview for axis-I disorders/Patient edition and by the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego auto-questionnaire, Young Mania Rating Scale, Hamilton Scale for Depression and for Anxiety, Brief Psychiatry Rating Scale, Clinical Global impression, Drug Attitude Inventory, Barratt Impulsiveness Scale, Toronto Alexithymia Scale, and Symptoms Checklist-90 items version, along with records of clinical and demographic data.

Results

The following prevalence rates for axis-I mood diagnoses were detected: bipolar disorder type I (BD-I, 28%), type II (31%), type not otherwise specified (BD-NOS, 33%), major depressive disorder (4%), and schizoaffective disorder (4%). Mean scores on the hyperthymic temperament scale were significantly higher in BD-I and BD-NOS, and in mixed and manic acute states. Hyperthymic temperament was significantly more frequent in BD-I and BD-NOS patients, whereas depressive temperament in BD-II ones. Hyperthymic and irritable temperaments were found more frequently in mixed episodes, while patients with depressive and mixed episodes more frequently exhibited anxious and depressive temperaments. Affective temperaments were associated with specific symptom and psychopathology clusters, with an orthogonal subdivision between hyperthymic temperament and anxious/cyclothymic/depressive/irritable temperaments. Therapeutic choices were often poorly differentiated among temperaments and mood states.

Limits

Cross-sectional design; sample size.

Conclusions

Although replication studies are needed, current results suggest that temperament-specific clusters of symptoms severity and psychopathology domains could be described.     

Affective temperaments in clinically-well subjects in Turkey: initial psychometric data on the TEMPS-A

BACKGROUND: This is a first attempt to evaluate the reliability and factor structure replicability of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) in its Turkish Version. The questionnaire is a self-report 110-item measure that postulates five affective temperaments-the depressive, cyclothymic, irritable, hyperthymic, and anxious-which embody both strengths and liabilities along affective lines. METHODS: The questionnaire was administered to 658 clinically-well subjects in a Turkish university circle. We undertook item analysis and test-retest reliability. We then examined internal consistency through factor analysis with PCA rotation. RESULTS: We found good to excellent test-retest reliability (0.73-0.91), and internal consistency (0.77-0.85). We deleted 10 items with factor loading <0.20 for their own subscales, resulting in a questionnaire with 99 items. Despite considerable overlap between depressive and cognitive anxiety traits, a distinct "nervous"-anxious factor emerged as well, and the hypothesized (original English) 5-factor structure of the TEMPS-A was supported. Cut-offs for each temperament were based on z-scores higher than +2S.D. Dominant irritable (3.7%), nervous-anxious (3.7%) and depressive (3.1%) temperaments were the most common in this population, whereas dominant cyclothymic (1.7%) and hyperthymic (1.2%) temperaments were relatively uncommon. These temperaments tended to lose their intensity with age. As expected, women scored significantly higher on the nervous-anxious, and men on the hyperthymic temperaments. LIMITATIONS: The sample was composed of younger subjects with higher education than the general population of Turkey. Although the distribution of the scores for each of the temperaments deviated somewhat from normal curves, for heuristic reasons we did attempt to provide prevalence rates based on z-scores. CONCLUSION: In this preliminary version of the TEMPS-A, we have retained 100 (of the original 110) traits loading >0.20. Some deleted items referred to sleep, others appeared socially desirability traits in the Turkish culture endorsed by many subjects. Nonetheless, item analyses within each factor revealed traits indicative of personal assets (specific to each temperament) along with those which might represent vulnerability to affective illness. This is in line with the hypothesized original theoretical framework of the senior authors. Even in this "first pass," in its Turkish version the TEMPS-A is a reliable and valid instrument. Further refinement of the instrument will require the study of a nationally representative sample in Turkey.     

TEMPS-A: validation of a short version of a self-rated instrument designed to measure variations in temperament

OBJECTIVE: To validate a short English-language version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-autoquestionnaire version (TEMPS-A), a self-report questionnaire designed to measure temperamental variations in psychiatric patients and healthy volunteers. Its constituent subscales and items were formulated on the basis of the diagnostic criteria for affective temperaments (cyclothymic, dysthymic, irritable, hyperthymic, and anxious), originally developed by the first author and his former collaborators. Further item wording and selection were achieved at a later stage through an iterative process that incorporated feedback from clinicians, researchers, and research volunteers. METHOD: A total of 510 volunteers (284 patients with mood disorders, 131 relatives of bipolar probands, and 95 normal controls) were recruited by advertisement in the newspapers, announcements on radio and television, flyers and newsletters, and word of mouth. All participants were interviewed using the Structured Clinical Interview for DSM-III-R, and completed the 110-item TEMPS-A and the Temperament and Character Inventory (TCI-125). The factorial structure, the alpha coefficients, and the item-total correlations coefficients of the TEMPS-A and the correlation coefficients between the dimensions of the TCI and the TEMPS-A subscales were then determined. RESULTS: A principal components analysis with a Varimax rotation found that 39 out of the 110 original items of the TEMPS-A loaded on five factors that were interpreted as representing the cyclothymic, depressive, irritable, hyperthymic, and anxious factors. Coefficients alpha for internal consistency were 0.91 (cyclothymic), 0.81 (depressive), 0.77 (irritable), 0.76 (hyperthymic), and 0.67 (anxious) subscales. We found statistically significant positive correlations between all-but the hyperthymic-subscales and harm avoidance. Positive correlations with the hyperthymic and cyclothymic, and novelty seeking and negative correlations with the remaining subscales were also recorded. Other major findings included positive correlations between the hyperthymic and reward dependence, persistence and self-directedness; positive correlation between the self-transcendence and the cyclothymic, hyperthymic and the anxious; and negative correlations between the depressive, cyclothymic, irritable, anxious and cooperativeness. LIMITATION: As the full-scale anxious temperament was added after the four scales of the TEMPS-A were developed, it has only been evaluated in 345 subjects. CONCLUSIONS: These data indicate that the TEMPS-A in its shortened version is a psychometrically valid scale with good internal consistency. The proposed five subscale structure is upheld. Concurrent validity against the TCI is shown. Most importantly, for each of the temperaments, we were able to show positive attributes which are meaningful in an evolutionary context, along with traits which make a person vulnerable to mood shifts. This hypothesized dual nature of temperament, which is upheld by our data, is a desirable characteristic for a putative behavioral endophenotype in an oligogenic model of inheritance for bipolar disorder.     

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

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

Validating antidepressant-associated hypomania (bipolar III): a systematic comparison with spontaneous hypomania (bipolar II)

BACKGROUND: According to DSM-IV and ICD-10, hypomania which occurs solely during antidepressant treatment does not belong to the category of bipolar II (BP-II). METHODS: As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 144 (29.2%) fulfilled the criteria for bipolar II with spontaneous hypomania (BP-II Sp), and 52 (10.5%) had hypomania associated solely with antidepressants (BP-H AA). RESULTS: BP-II Sp group had earlier age at onset, more hypomanic episodes, and higher ratings on cyclothymic and hyperthymic temperaments, and abused alcohol more often. The two groups were indistinguishable on the hypomania checklist score (12.2+/-4.0 vs. 11.4+/-4.4, respectively, P=0.25) and on rates of familial bipolarity (14.1% vs. 11.8%, respectively, P=0.68). But BP-H AA had significantly more family history of suicide, had higher ratings on depressive temperament, with greater chronicity of depression, were more likely to be admitted to the hospital for suicidal depressions, and were more likely to have psychotic features; finally, clinicians were more likely to treat them with ECT, lithium and mood stabilizing anticonvulsants. LIMITATION: Naturalistic study, where treatment was uncontrolled. CONCLUSION: BP-H AA emerges as a disorder with depressive temperamental instability, manifesting hypomania later in life (and, by definition, during pharmacotherapy only). By the standards of clinicians who have taken care of these patients for long periods of time, BP-H AA appears as no less bipolar than those with prototypical BP-II. We submit that familial bipolarity ('genotypic' bipolarity) strongly favors their inclusion within the realm of bipolar II spectrum, as a prognostically less favorable depression-prone phenotype of this disorder, and which is susceptible to destabilization under antidepressant treatment. These considerations argue for revisions of DSM-IV and ICD-10 conventions. BP-HAA may represent a genetically less penetrant expression of BP-II; phenotypically; it might provisionally be categorized as bipolar III.     

Cocaine abuse and the bipolar spectrum in 1090 heroin addicts: clinical observations and a proposed pathophysiologic model

BACKGROUND: Several studies indicate a specific relationship between bipolar disorder and stimulant use and abuse. It has generally been assumed that cocaine use represents self-enhancement or attempts to optimize one's level of hypomania, cyclothymia or hyperthymia. This topic required further examination among heroin abusers because cocaine abuse is commonly comorbid with heroin abuse. METHODS: Cocaine abuse by bipolar subjects was investigated in a group of 1090 treatment-seeking heroin addicts enrolled between 1994 and 2005. We collected data with 1) the Drug Addiction History Rating Scale; and 2) the Semi-structured Interview for Depression, which inquires systematically among others, about hypomania, cyclothymia, hyperthymia and depressive temperament. Subjects were aged 29+/-6 years, and predominantly male (76.2%). RESULTS: Univariate and multivariate analyses provided correlations in favour of a link between current cocaine abuse and double diagnosis, with special relevance to the bipolar spectrum, as well as psychotic disorders (p<0.0001). LIMITATION: The modality of access to cocaine in different communities and the difficulty to distinguish cocaine use from abuse by the rating scale administered may have limited the interpretation of results. CONCLUSIONS: If cocaine abuse precedes that of heroin or is concomitant, heroin may hypothetically serve as a "mood balancer" which transiently dampens subthreshold excitatory states and mood swings. Our data further suggest the need for a more complex model linking cocaine and bipolarity: subthreshold bipolarity, including hyperthymic and cyclothymic temperaments, seems to predispose to heroin addiction, but craving for the suppressed hypomania in turn could lead to cocaine abuse, which eventually unmasks a frank bipolar disorder - in some cases leading to mixed state, severe mania, as well as psychosis beyond mania. Prospective observations would shed further insight on this complex interface of major clinical and public health importance.     

The 5HTTLPR polymorphism of the serotonin transporter gene is associated with affective temperaments as measured by TEMPS-A

BACKGROUND: Increasing evidence supports the notion of a continuum between affective temperaments and major mood disorders, suggesting that these temperament types represent the subclinical manifestations of affective disorders and often present an increased vulnerability for these diseases. METHODS: The Hungarian rendition of the full-scale 110-item version of the TEMPS-A questionnaire and 5HTTLPR genotype was investigated in a sample of 139 unrelated Caucasian females with no current or lifetime Axis I psychiatric disorders. RESULTS: A significant association was found between the s allele and the TEMPS scores of the depressive, anxious, irritable, and particularly the cyclothymic temperaments; no such association emerged with respect to the hyperthymic temperament. LIMITATION: The database is entirely female. Given that the hyperthymic type predominates in males, our results could have been different if men were included in our sample. CONCLUSIONS: Our results are in good agreement with earlier studies reporting a strong association between the s allele of the 5HTTLPR and major as well as subthreshold forms of depression, and extend this association to the normative temperament level. Indeed, these temperaments might best be regarded as proximate behavioural endophenotypes. Our data raise the provocative possibility that the genetic potential for mood episodes lies in these temperaments. Further studies are needed to delineate the role of gender in the associations under consideration, as well as to investigate the genetic background of the hyperthymia-mania part of the affective spectrum. Given that affective temperaments are widely distributed in the general population, the strategy employed by us is of potential public health significance in terms of detecting individuals in the community at risk for affective spectrum disorders.     

Validation of the TEMPS-A Buenos Aires: Spanish psychometric validation of affective temperaments in a population study of Argentina

BACKGROUND: The TEMPS-A (Temperament Evaluation of Memphis, Pisa, Paris and San Diego) is a 110-item questionnaire in five scales which has been translated into over 25 language versions: American, Italian (only for Interview version or TEMPS-I), French, Lebanese, Hungarian, Japanese and Turkish versions have already been validated. There are two Spanish versions, one from Barcelona, and the present one from Buenos Aires. This study represents the first attempt at validating the TEMPS-A in Spanish. METHODS: 932 clinically well subjects were studied, of both sexes (62% female) with mean+/-SD age of 35.4+/-18.1. Standard psychometric tests of reliability and validation were performed. RESULTS: Chronbach alphas were 0.7 (depressive) and 0.8 (anxious, cyclothymic, irritable and hyperthymic). In exploratory factor analyses, the hyperthymic was distinct from the others. As expected, the depressive and anxious correlated strongly, so did the cyclothymic and anxious. Dominant temperaments ranged from 2.1% to 4.5% of the population under study, except for the hyperthymic which had a negligible rate of 0.2% (but accounted for 13% between +1 SD and +2 SD). LIMITATION: We did not examine test-to-test reliability. CONCLUSIONS: This is the first validation of the TEMPS-A in Spanish, the Buenos Aires version with the original 110 items, with very good psychometric properties.