Bipolar disorder and comorbid attention deficit hyperactivity disorder. A distinct clinical phenotype? Clinical characteristics and temperamental traits1

Abstract

Objectives. It has been suggested that bipolar disorder (BD) with comorbid ADHD represents a distinct clinical phenotype of BD. There are no data regarding potential heterogeneity between BD subjects with a diagnosis of ADHD in childhood whose ADHD remitted in adulthood (cADHD-BD) vs. BD patients with persistent ADHD diagnosis in adulthood (aADHD-BD). This heterogeneity may constitute a confounder in investigations of the nature of the co-occurrence between BD and ADHD. The aim of this paper is to compare BD patients without ADHD, to those with aADHD-BD, and those with cADHD-BD on clinical and temperamental characteristics, hypothesizing that maladaptive temperament will be increased in BD subjects with a stable diagnosis of ADHD in adulthood compared to those whose ADHD remitted. We further hypothesize that maladaptive temperament will be associated with the severity of both illnesses. Methods. A total of 100 outpatients (aged 18–30 years) with BD in remission were included. The assessment of ADHD was made according to a procedure aimed to reduce potential recall biases. Subjects had to have a parent available and had never been treated with stimulants. Temperamental traits were assessed with the California Child Q-sort (CCQ) and the Early Adolescent Temperament Questionnaire (EATQ). Results. Rate of co-occurrence of ADHD-BD was 18% lifetime and 10% current diagnosis. Patients with ADHD-BD (aADHD-BD+cADHD-BD) reported a significantly earlier onset of mood disorder, higher number of previous mood episodes, and significantly higher impulsivity than BD patients without ADHD. aADHD-BD showed a significantly earlier BD onset, higher number of previous mood episodes, higher impulsivity, decreased Reactive Control and higher Negative Emotionality temperamental scores than cADHD patients. Conclusion. Findings suggest that patients with aADHD-BD present a clinical phenotype distinct from that of patients with BD without ADHD or with a childhood ADHD diagnosis that remitted with the age. This appealing hypothesis of a BD-distinct phenotype that can be detected early due to its associated maladaptive temperamental traits requires further investigation in larger samples, supported by neuropsychological, genetic and imaging data.     

The potential use of biomarkers as an adjunctive tool for staging bipolar disorder

Recent data show that biomarkers differ in early and late-stage bipolar disorder (BD). Here we propose a model of staging for bipolar disorder that emphasizes the potential use of biomarkers for differentiating early and late-stage BD patients in the inter-episodic period. The proposed model includes a Latent phase: patients at “ultra-high-risk” for developing BD, characterized by a family history of BD, temperament traits, mood, and anxiety symptoms as well as genetic vulnerability for developing the disorder; Stage I: patients who return to their baseline level of functioning when mood episodes resolve; Stage II: biomarkers and functioning impairment are related to comorbidities or rapid-cycling presentations; Stage III: persistent cognitive and functioning impairment in the inter-episode period as well as changes in biomarkers; and Stage IV: same findings as in Stage III associated with extreme cognitive and functioning impairment, to the point that patients are unable to live autonomously. Empirical testing will determine the ability of the present model to inform patients and clinicians about both prognosis and response to treatment.     

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

Background and aims: Treatment adherence is one of the most important factors that may determine treatment response in patients with bipolar disorders (BD). Many factors have been described to be associated with treatment adherence in BD. Temperament that can influence the course of BD will have an impact on treatment adherence. The aim of this study is to investigate temperament effect on treatment adherence in euthymic patients with BD-I. Methods: Eighty patients with BD-I participated in the study. A psychiatrist used the Structured Clinical Interview for DSM-IV Axis-I Disorders to determine the diagnosis and co-morbidities. Hamilton Depression and Young Mania Rating Scale were used to detect the remission. We used the Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire and the 4-item Morisky Medication Adherence Scale to evaluate temperament and treatment adherence, respectively. The study group was divided into two groups as “treatment adherent” and “treatment non-adherent”. Results: The cyclothymic and anxious temperament scores of the treatment non-adherent patients with BD-I were significantly higher than those of the treatment adherent group (p < 0.001, p = 0.006, respectively). Multiple linear regression analysis determined that cyclothymic temperament predicted treatment non-adherence (p = 0.009). Conclusion: It should be kept in mind that BD-I patients with cyclothymic temperament may be treatment non-adherent and future studies should explore whether temperament characteristics deteriorate BD-I course by disrupting treatment adherence.     

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

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

The impact of personality on quality of life and disease activity in patients with Behcet’s disease: a pilot study

Background

The aim of this study was to examine the personality characteristics of patients with Behcet’s Disease (BD) using the Temperament and Character Inventory (TCI) compared with healthy control subjects and to investigate the relationship between the temperament and character properties and quality of life, disease activity, depression and anxiety in Behcet’s patients.

Methods

A total of 46 BD patients and 40 healthy subjects were included in the study. All patients and controls were determined using the TCI, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Clinical Version for Axis I disorders (SCID-CV), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Quality of life (QOL) Instrument for Skin Disorders and Behcet Disease Current Activity Form (BDCAF).

Results

BD patients demonstrated significantly lower Reward Dependence than healthy controls. Among the subscales; Explarotory Excitability, Shyness with Strangers, Attachment, Spiritual Acceptance were lower and Self-Acceptance was higher in patients compared to control subjects. Decreased quality of life and increased disease activity of the patients were correlated with increased anxiety and depression. Responsibility, Self-Forgetfulness and Transpersonal Identification were associated with quality of life while Responsibility was the major factor effecting QOL. Disease activity was not found related with TCI properties.

Conclusion

Temperament and Character traits of BD patients were different from healthy group that might be due to many factors like genetics, biological or socio-cultural differences. BD patients were demonstrated as materialistic, self-contained, self-confident, cold, detached, and reserved although they are not shy. Considering the different personality traits of BD patients in psychotherapeutic approaches, may have a positive impact on QOL and comorbid major depressive disorder.     

Temperaments mediate suicide risk and psychopathology among patients with bipolar disorders

BackgroundSeveral studies have demonstrated that bipolar II (BD-II) disorder represents a quite common, distinct form of major mood disorders that should be separated from bipolar I (BD-I) disorder. The aims of this cross-sectional study were to assess temperament and clinical differences between patients with BD-I and BD-II disorders and to assess whether temperament traits are good predictors of hopelessness in patients with bipolar disorder, a variable highly associated with suicidal behavior and ideation.MethodParticipants were 216 consecutive inpatients (97 men and 119 women) with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), BD who were admitted to the Sant'Andrea Hospital's psychiatric ward in Rome (Italy). Patients completed the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego—Autoquestionnaire, the Beck Hopelessness Scale (BHS), the Mini International Neuropsychiatric Interview (MINI), and the Gotland Scale of Male Depression.ResultsPatients with BD-II had higher scores on the BHS (9.78 ± 5.37 vs 6.87 ± 4.69; t_143.59 = ?3.94; P < .001) than patients with BD-I. Hopelessness was associated with the individual pattern of temperament traits (ie, the relative balance of hyperthymic vs cyclothymic-irritable-anxious-dysthmic). Furthermore, patients with higher hopelessness (compared with those with lower levels of hopelessness) reported more frequently moderate to severe depression (87.1% vs 38.9%; P < .001) and higher MINI suicidal risk.ConclusionTemperaments are important predictors both of suicide risk and psychopathology and may be used in clinical practice for better delivery of appropriate care to patients with bipolar disorders.     

Personality and Temperament Correlates of Pain Catastrophizing in Young Adolescents

Pain catastrophizing is generally viewed as an important cognitive factor underlying chronic pain. The present study examined personality and temperament correlates of pain catastrophizing in a sample of young adolescents (N = 132). Participants completed the Pain Catastrophizing Scale for Children, as well as scales for measuring sensitivity of the behavioral inhibition and behavioral activation systems (BIS-BAS), and various reactive and regulative temperament traits. Results demonstrated that BIS, reactive temperament traits (fear and anger-frustration), and perceptual sensitivity were positively related to pain catastrophizing, whereas regulative traits (attention control, inhibitory control) were negatively associated with this cognitive factor. Further, regression analyses demonstrated that only BIS and the temperamental traits of fear and perceptual sensitivity accounted for a unique proportion of the variance in adolescents’ pain catastrophizing scores.     

Relationship of dissociation to temperament and character in men and women.

OBJECTIVE: This study approaches the question of nature and nurture of dissociative phenomena. Within Cloninger's concept of personality, character traits are thought to develop in response to environmental stimuli and conditions during childhood and adolescence, whereas temperament traits are considered to be genetically predisposed. The hypothesis is tested that dissociative symptoms are associated with distinct character traits but not with temperament dimensions. METHOD: Psychiatric patients (N = 191) and healthy subjects (N = 41) were evaluated for dissociative symptoms (Dissociative Experience Scale), temperament and character (Temperament and Character Inventory), and current psychopathology (SCL-90-R). Regression analyses for women and men were calculated separately. RESULTS: For both genders, the character traits of self-transcendence and self-directedness were significant and independent predictors for dissociation. CONCLUSIONS: These results support the hypothesis that dissociative symptoms are caused by environmental factors and point against a genetic predisposition in the development of dissociative symptoms.     

Parental care-giving and home environment predicting offspring's temperament and character traits after 18 years

Although many personality theories emphasize the role of parental behaviors in shaping personality development, empirical data from longitudinal studies remain scarce. It is also not known, if parental behaviors affect character development more strongly than temperament or vice versa. In a prospective study, 1083 volunteer participants of the Young Finns study completed the Temperament and Character Inventory (TCI). Parents of the participants had answered questions about parenting attitudes, socioeconomic status, health behaviors, and role satisfaction 18 years before. We studied the univariate and the cumulative effects of parental care-giving and family environment on offspring's personality traits. Parental care-giving and home-environment were more strongly associated with offspring character traits reflecting personality maturity (Self-directedness and Cooperativeness) than with offspring temperament traits (Novelty seeking, Harm avoidance, Reward dependence and Persistence) reflecting emotional and behavioral tendencies. The differences were most evident in the cumulative effects model. Maternal variables were stronger predictors than paternal variables. The present findings suggest that not all personality traits are similarly predicted by parental care-giving and home-environment. In particular, character development is more strongly related to such measures than temperament. Parental care-giving and home-environment are more strongly related to psychological maturity (character) than emotional and behavioral tendencies (temperament).     

Self-reported reactive and regulative temperament in early adolescence: relations to internalizing and externalizing problem behavior and "Big Three" personality factors

The present study examined the relations between self-reported reactive and regulative temperament factors and psychopathological symptoms and personality traits in a group of non-clinical youths aged 9-13 years (N=208). Results showed that the reactive temperament factor of negative affectivity was positively associated with internalizing and externalizing symptoms, whereas the regulative temperament factor of effortful control was negatively related to such symptoms. Further analyses provided some support for the notion that in particular the combination of high negative affectivity and low effortful control was associated with high symptom levels. Results also revealed specific relations between lower-order temperament traits and internalizing and externalizing symptoms. That is, fear and (low) attention control appeared to be more clearly associated with internalizing symptoms, whereas anger/frustration and (low) activation and inhibitory control were more convincingly linked to externalizing symptoms. Finally, relations with the "Big Three" personality traits were as anticipated, with high positive correlations between negative affectivity and extraversion/surgency and their Eysenckian counterparts of neuroticism and extraversion, respectively.     

Temperament,Personality and Developmental Psychopathology: A Review Based on the Conceptual Dimensions Underlying Childhood Traits

The numerous temperament and personality constructs in childhood impede the systematic integration of findings on how these individual differences relate to developmental psychopathology. This paper reviews the main temperament and personality theories and proposes a theoretical taxonomy representing the common structure of both temperament and personality traditions within one conceptual framework. This integrated lexicon of childhood temperament/personality traits facilitates an overview of the most important research findings on the role of temperament and personality in the development of anxiety, depression, ADHD, proactive and reactive antisocial behavior. Several directions for future research are discussed to further validate and refine these reviewed relationships.     

Temperamental Characteristics in Adults with Attention-Deficit Hyperactivity Disorder: A Comparison with Bipolar Disorder and Healthy Control Groups

Objective

To date, the affective temperamental characteristics of adults with attention-deficit hyperactivity disorder (ADHD) have not been studied. The aim of this study is to explore those temperamental characteristics for adults diagnosed with ADHD as measured by the TEMPS-A and then to compare those results with results for individuals diagnosed with bipolar disorder (BD) and with healthy controls.

Methods

Forty adults with ADHD, 40 patients with BD, and 40 healthy controls were enrolled in this study. The groups were matched by age and gender. All patients were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I), the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Young Mania Rating Scale and the Wender Utah Rating Scale. Subjects'' temperamental characteristics were examined using the Turkish version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto questionnaire (TEMPS-A).

Results

Ten subjects (25%) in the ADHD group and 15 subjects (30%) in the bipolar group had at least one dominant temperament. There was no identifiable dominant temperament in the control group. Compared to the control group, the ADHD group scored higher than other groups on all domains of the TEMPS-A: depressive cyclothymic, irritable and anxious. However, the hyperthymic domain was not higher for this group. Adults with ADHD scored higher on the irritable temperament scale as compared to the BD group. The ADHD and BD groups had similar mean scores for each of the other four temperaments.

Conclusion

The adults diagnosed with ADHD in this study had different temperamental characteristics from the control group, and these temperamental characteristics were similar to those of the bipolar patients. Recognizing the role of temperamental characteristics in adults with ADHD may increase our understanding of ADHD.     

Temperament and executive dysfunctions in schizophrenia

Recent studies suggest that both executive dysfunction and personality traits combine with symptoms to affect the social outcome of persons with schizophrenia. This study was designed to investigate how personality traits influence executive function in schizophrenia. Forty-four patients with schizophrenia and twenty-two healthy subjects were assessed for personality using the temperament and character inventory. Different aspects of executive function were assessed using the Auditory Digit Span (forward and backward) and the Wickens' test for proactive interference and release. The results showed that the influences of the various temperament dimensions on specific aspects of executive functions differ between patients and healthy subjects. On some dimensions, schizophrenia appears to reduce the cognitive differences related to temperament. On other dimensions, schizophrenia tends to reverse the cognitive differences related to temperament observed in healthy people. These results suggest that the temperamental profile of schizophrenia patients may well be of important prognostic value in the planning of cognitive enhancement therapy.     

Temperament and parenting predicting anxiety change in cognitive behavioral therapy: The role of mothers,fathers, and children

ObjectiveA considerable amount of children with anxiety disorders do not benefit sufficiently from cognitive behavioral treatment. The present study examines the predictive role of child temperament, parent temperament and parenting style in the context of treatment outcome.MethodParticipants were 145 children and adolescents (ages 8–18) with DSM-IV-TR anxiety disorders who received a 12-session CBT program and were assessed at pretreatment, posttreatment and three months follow-up. Multiple-regression analyses were used to evaluate the following pretreatment and posttreatment variables as potential predictors of treatment response at follow-up: baseline level of anxiety symptoms, child reported maternal and paternal rearing style (emotional warmth, rejection, and overprotection), parent reported child temperament traits (negative affect, effortful control, and extraversion), and mothers’ and fathers’ self-report temperament traits.ResultsMore maternal negative affect and less emotional warmth as perceived by the child before treatment were related to less favorable treatment outcome (accounting for 29% of the variance in anxiety at follow-up). Furthermore, maternal negative affect and children's extraversion measured after treatment also predicted anxiety at follow-up (together accounting for 19% of the variance). Paternal temperament and parenting style were unrelated to treatment outcome, as were children's pretreatment temperament traits.ConclusionThe results suggest that tailoring intervention to include strategies to reduce maternal negative affect and promote an emotional warm rearing style may improve treatment outcome.     

The genetic association between personality and major depression or bipolar disorder. A polygenic score analysis using genome-wide association data

The relationship between major depressive disorder (MDD) and bipolar disorder (BD) remains controversial. Previous research has reported differences and similarities in risk factors for MDD and BD, such as predisposing personality traits. For example, high neuroticism is related to both disorders, whereas openness to experience is specific for BD. This study examined the genetic association between personality and MDD and BD by applying polygenic scores for neuroticism, extraversion, openness to experience, agreeableness and conscientiousness to both disorders. Polygenic scores reflect the weighted sum of multiple single-nucleotide polymorphism alleles associated with the trait for an individual and were based on a meta-analysis of genome-wide association studies for personality traits including 13 835 subjects. Polygenic scores were tested for MDD in the combined Genetic Association Information Network (GAIN-MDD) and MDD2000+ samples (N=8921) and for BD in the combined Systematic Treatment Enhancement Program for Bipolar Disorder and Wellcome Trust Case–Control Consortium samples (N=6329) using logistic regression analyses. At the phenotypic level, personality dimensions were associated with MDD and BD. Polygenic neuroticism scores were significantly positively associated with MDD, whereas polygenic extraversion scores were significantly positively associated with BD. The explained variance of MDD and BD, ∼0.1%, was highly comparable to the variance explained by the polygenic personality scores in the corresponding personality traits themselves (between 0.1 and 0.4%). This indicates that the proportions of variance explained in mood disorders are at the upper limit of what could have been expected. This study suggests shared genetic risk factors for neuroticism and MDD on the one hand and for extraversion and BD on the other.     

Personality traits and schizophrenia: evidence from a case-control study and meta-analysis

Personality is considered to be an important aspect of schizophrenia, primarily because it may influence patients' symptoms and social functioning. Specific personality traits are related to schizophrenia. The Temperament and Character Inventory (TCI) measures four traits of temperament - novelty seeking (NS), harm avoidance (HA), reward dependence (RD) and persistence (PS) - and three traits of character - self-directedness (SD), cooperativeness (CO) and self-transcendence (ST). We investigated associations between schizophrenia and personality traits using the TCI in a Japanese case-control sample (99 patients and 179 controls). Patients with schizophrenia scored higher on HA and ST and lower on NS, RD, SD and CO compared with controls in our case-control sample. We then performed a meta-analysis of samples from the published literature and our sample (384 patients and 656 controls). We found no evidence of heterogeneity among studies, except for NS in the overall population. Possible associations between personality traits (HA, RD, PS, SD, CO and ST) and schizophrenia were revealed. The effect sizes (Hedges' g) of the temperament traits were 0.98 for HA, -0.43 for RD and -0.23 for PS, and those of the character traits were -0.96 for SD, -0.47 for CO and 0.61 for ST. These findings suggest that patients with schizophrenia have a unique temperament and character profile compared with the general population.     

Temperament and Sensory Features of Children with Autism

This study sought to characterize temperament traits in a sample of children with autism spectrum disorder (ASD), ages 3-7?years old, and to determine the potential association between temperament and sensory features in ASD. Individual differences in sensory processing may form the basis for aspects of temperament and personality, and aberrations in sensory processing may inform why some temperamental traits are characteristic of specific clinical populations. Nine dimensions of temperament from the Behavioral Style Questionnaire (McDevitt and Carey in Manual for the behavioral style questionnaire, Behavioral-Developmental Initiatives, Scottsdale, AZ, 1996) were compared among groups of children with ASD (n?=?54), developmentally delayed (DD; n?=?33), and the original normative sample of typically developing children (McDevitt and Carey in J Child Psychol Psychiatr 19(3):245-253, 1978; n?=?350) using an ANOVA to determine the extent to which groups differed in their temperament profiles. The hypothesized overlap between three sensory constructs (hyperresponsiveness, hyporesponsivness, and seeking) and the nine dimensions of temperament was analyzed in children with ASD using regression analyses. The ASD group displayed temperament scores distinct from norms for typically developing children on most dimensions of temperament (activity, rhythmicity, adaptability, approach, distractibility, intensity, persistence, and threshold) but differed from the DD group on only two dimensions (approach and distractibility). Analyses of associations between sensory constructs and temperament dimensions found that sensory hyporesponsiveness was associated with slowness to adapt, low reactivity, and low distractibility; a combination of increased sensory features (across all three patterns) was associated with increased withdrawal and more negative mood. Although most dimensions of temperament distinguished children with ASD as a group, not all dimensions appear equally associated with sensory response patterns. Shared mechanisms underlying sensory responsiveness, temperament, and social withdrawal may be fruitful to explore in future studies.     

Comparative Study of Personality Traits in Patients with Bipolar I and II Disorder from the Five-Factor Model Perspective

Objective

The distinguishing features of Bipolar I Disorder (BD I) from Bipolar II Disorder (BD II) may reflect a separation in enduring trait dimension between the two subtypes. We therefore assessed the similarities and differences in personality traits in patients with BD I and BD II from the perspective of the Five-Factor Model (FFM).

Methods

The revised NEO Personality Inventory (NEO-PI-R) was administered to 85 BD I (47 females, 38 males) and 43 BD II (23 females, 20 males) patients. All included patients were in remission from their most recent episode and in a euthymic state for at least 8 weeks prior to study entry.

Results

BDII patients scored higher than BD I patients on the Neuroticism dimension and its four corresponding facets (Anxiety, Depression, Self-consciousness, and Vulnerability). In contrast, BD II patients scored lower than BD I patients on the Extraversion dimension and its facet, Positive emotion. Competence and Achievement-striving facets within the Conscientiousness dimension were significantly lower for BD II than for BD I patients. There were no significant between-group differences in the Openness and Agreeableness dimensions.

Conclusion

Disparities in personality traits were observed between BD I and BD II patients from the FFM perspective. BD II patients had higher Neuroticism and lower Extraversion than BD I patients, which are differentiating natures between the two subtypes based on the FFM.     

Temperament and its role in developmental psychopathology

Temperament refers to early-appearing variation in emotional reactivity. The core dimensions of temperament and optimal method for assessment continue to be sources of considerable discussion. Nevertheless, the moderate stability of most temperamental traits and the strong influence of genetic and unique environmental factors have been well established, along with temperament's association with childhood psychiatric disorders. Both temperamental predisposition toward experiencing negative emotions and low inhibitory control are linked to many psychiatric conditions, while other dimensions, such as levels of extraversion, vary by, and likely even within, disorders. Accumulating research directed at understanding the mechanism of these links between temperament and psychopathology indicate that, at least for most disorders, the two constructs cannot be viewed as simply different points along a shared continuum. The effect of temperament upon psychopathology has been found to be mediated and moderated by a number of both internal and external factors. Additional research is needed to help further define the core dimensions of temperament and the complex mechanisms through which temperamental traits interact with other influences in affecting developmental trajectories.     

Family correlates of temperament continuity and change across middle childhood

This paper reports on continuity and change of extreme traits of temperament from age seven to 12 in subgroups selected from a large random sample and on the association of continuity with certain aspects of family functioning. Results suggest a definite degree of stability of extreme temperament over time. Implications of the findings are discussed and directions for future research suggested.