Journal of Affective Disorders 56 (1999) 103–108www.elsevier.com/ locate / jad

Research report

Temperament in bipolar illness: impact on prognosis

a , a b a* ˆ´ ´ `Chantal Henry , Jerome Lacoste , Frank Bellivier , Helene Verdoux ,a b ,cMarc L. Bourgeois , Marion Leboyer

a ´Service Universitaire de Psychiatrie, CHS Charles Perrens, 121 rue de la Bechade, 33076 Bordeaux Cedex, Franceb ´ ˆ ´ ´ `Laboratoire de Recherche sur les Personnalites et les Conduites Adaptatives, CNRS UMR 7593, Hopital Pitie-Salpetriere, Paris,

Francec ˆ ˆ ´ ´ `Service de Psychiatrie Adulte, Assistance Publique–Hopitaux de Paris, Hopital Pitie-Salpetriere, Paris, France

Received 21 July 1998; received in revised form 25 October 1998; accepted 20 November 1998

Abstract

Objective: The present study was designed to investigate the relations between temperament and outcome in bipolarillness. Methods: Seventy-two patients presenting with bipolar type I disorder were recruited from consecutive admissionsand evaluated when euthymic. The criteria developed by Akiskal and Mallya (Criteria for the ‘soft’ bipolar spectrum:treatment implications. Psychopharmacol. Bull. 1987;23:68–73) were used to assess both depressive (DT) and hyperthymictemperaments (HT) in a dimensional approach. Results: Multiple regression analysis showed that a higher DT score or alower HT score were significantly associated with a greater number of episodes. Furthermore, a higher DT score wasstrongly associated with a higher percentage of major depressive episodes. Conversely, a higher HT score was associatedwith a trend to manic rather than depressive episodes. Suicide attempts appeared more frequent in the history of patientspresenting with higher DT scores. Conclusions: Our findings strengthen the hypothesis that temperament is one of the mainvariables accounting for some features in the clinical evolution of bipolar disorder such as polarity of episodes. Furthermore,these findings are consistent with the hypothesis of a trait-state continuum between personality and affective episodes. 1999 Elsevier Science B.V. All rights reserved.

Keywords: Bipolar disorder; Prognosis; Hyperthymic temperament; Depressive temperament; Suicide attempts; Manic episodes; Depressiveepisodes

1. Introduction ders. In his attempt to account for the recurrence ofaffective episodes, he postulated the existence of

Kraepelin (1921) was among the first author to enduring personality characteristics, from which thepay systematic attention to the premorbid charac- affective states arose. Thus, depressive, manic, irrit-teristics of patients suffering from affective disor- able and cyclothymic personalities were considered

the temperamental bases of the full-blown forms ofthe illness. The Kraepelin (1921) hypothesis was*Corresponding author. Tel.: 1 33-556-563448; fax: 1 33-556-based on the observation that affective temperaments563546.

E-mail address: chantal.henry@bordeaux.inserm.fr (C. Henry) occurred in the premorbid histories of most of

0165-0327/99/$ – see front matter 1999 Elsevier Science B.V. All rights reserved.PI I : S0165-0327( 98 )00219-5

104 C. Henry et al. / Journal of Affective Disorders 56 (1999) 103 –108

manic-depressive probands who returned to their disorder were recruited from consecutive admissionsbasic temperament rather than to ‘normality’ on to a unit serving an urban geographic area in theremission; furthermore, such temperaments, without Bordeaux psychiatric hospital. All patients gaveprogression to full-blown illness, were over-repre- written informed consent. Patients were interviewedsented in the biologic relatives of manic-depressive by trained psychiatrists (CH and JL) with a Frenchprobands. The work of Schneider (1958) extended version of the Diagnosis Interview for GeneticKraepelin’s observations and led to descriptions of Studies (Nurnberger et al., 1994) providing DSM IVthe depressive and hypomanic types which are the Axis I diagnoses. Best estimate based on consensustwo basic temperaments in the Kraepelinian scheme. between the interviewer and an independentKretschmer (1936) postulated a continuum between psychiatrist was obtained for the following anamnes-the cyclothymic character and manic-depressive psy- tic data: number of previous episodes, number ofchosis. manic and depressive episodes, type of first episode,

More recently, some authors (Von Zerssen and age at first hospitalization, history of suicide at-Possl, 1990; Akiskal and Akiskal, 1992) suggested tempts, and sociodemographic data. At the time ofthat one of the major point of interest with tempera- interview, which usually took place at the end of thement is to be able to explore the clinical and hospital stay, patients had recovered from their mostpredictive significance of subaffective traits in order recent episode.to understand the premorbid traits and interepisodicmanifestations of recurrent mood disorders within a 2.2. Rating scalesspectrum of bipolar illness. Thus, Akiskal (1995)showed that dysthymic, cyclothymic, and hyper- To evaluate temperamental aspects, we used de-thymic temperaments represent putative developmen- pressive and hyperthymic temperament criteria de-tal pathways to bipolarity in childhood and adolesc- veloped by Akiskal and Mallya (1987). We used theence with clinically ascertained depressions. French version of the Semi-structured Interview of

Other studies have focused on the fact that tem- these temperaments based upon the University ofperaments may broaden the spectrum of bipolar Tennessee modification (Akiskal and Mallya, 1987).disorders. Cassano et al. (1989) showed that in This French version has criteria regarding the subaf-unipolar disorder with hyperthymic temperament, fective feature of temperaments like sleep durationfamily history and sex distribution have a closer and energy level (Bourgeois et al., 1997). These tworesemblance to those of bipolar I and II disorders interviews (one for hyperthymic and one for depres-rather than pure unipolar disorder (without hyper- sive temperament) were composed of 22 items aboutthymic temperament). Therefore, the bipolar spec- usual mood, cognition, psychomotricity, personaltrum for these authors includes hyperthymic or interrelations, attitudes to social norms, sleep needs,cyclothymic temperaments associated with major and sexual appetite. Answers were selected by thedepressions (Akiskal, 1983; Akiskal et al., 1983; patient himself and not by the scorer. One point wasCassano et al., 1992). counted per positive item. All patients were assessed

However, only few studies have investigated the using the two interviews and had a score for bothrelationships between hyperthymic or depressive temperaments. These tools are usually used to dis-temperaments and the main characteristics of bipolar tinguish sub-groups of patients. In this case, eachdisorder. The aim of the present study is to explore temperament requires the presence of at least fivethe impact of temperamental status differences on the items and both diagnoses are mutually exclusive.evolution of bipolar illness. Some patients cannot be classified in any of category

because they lack the number of items. In a study byPerugi et al. (1990) only 59% of bipolar type I

2. Methods patients could be characterized on their baselinetemperament with this approach. We chose to con-

2.1. Subjects sider this temperamental characteristic as a dimen-sion rather than a category. Indeed, the analysis of

Seventy-two patients presenting with bipolar I score distribution in both temperament scales does

C. Henry et al. / Journal of Affective Disorders 56 (1999) 103 –108 105

not evidence a bi- or tri-modal distribution allowing patients had always been single, and 39 (54.2%)us to establish non-arbitrary thresholds in the consti- patients were married, divorced, or widowed.tution of categories. Furthermore, the advantage of a By defining the onset of the first symptomsdimensional approach is that no patient is excluded. meeting DSM IV criteria for an affective episode, weOnly these two temperament subtypes were used found that the mean age for the first depressivebecause they represent two opposing symmetrical episode in this population was 26.9 (S.D. 9) and 30traits. (S.D. 10.8) for the first manic episode. The propor-

tion of bipolar patients who began their illness with a2.3. Statistical analysis manic episode was 31.9%, and was 58.3% for those

whose first episode was depressive (no reliableStatistical analysis were carried out using SPSS information was available for 9.8% patients).

software (Norusis, 1992). Associations between cate- Patients were clinically euthymic when includedgorical variables and temperaments dimensions as confirmed by the mean MADRS scores 5 2.3scores were examined using logistic regression, (S.D. 2.9) (Montgomery and Asberg, 1979) and theyielding odds ratios (OR) and 95% confidence mean Bech and Rafaelsen Mania Rating Scaleintervals (CI). Multiple regression analyses yielding scores 5 2.7 (S.D. 2.2) (Bech et al., 1978).regression coefficients (B) and 95% confidenceintervals (CI) were used to examine the relationshipsbetween continuous variables and dimensions scores. 3.2. Associations between characteristics of illnessDistributions of continuous variables were examined, and temperamentsand log-transformations or square-transformationswere made in order to remove skewness where As indicated in Table 1, logistic or multipleappropriate. Regression models were subsequently regressions indicated that hyperthymic temperamentcomputed adjusted for potential confounding vari- (HT) scores, as well as depressive temperamentables, which were selected a priori and not on the (DT) scores were significantly correlated with somebasis of statistical significant association with the clinical characteristics of bipolar disorders. The totaldependent and explanatory variables (Clayton and number of manic or depressive episodes was posi-Hills, 1993). Residuals were examined for evidence tively correlated to the DT score (B 5 0.06; CI (0.02;of non-linearity. Departure from linearity was also 0.11); P 5 0.01) and negatively to the HT scoreexamined by adding square clinical rating score (B 5 2 0.05; CI (20.09; 20.009); P 5 0.02). Thisterms to the model and assessing subsequent im- trend was not abolished after adjustment for age, sexprovement in the model fit. and educational level. Furthermore, the percentage of

manic episodes was positively correlated to the HTscore (B 5 0.008; CI (0.00; 0.02); P 5 0.04), where-

3. Results as the negative correlation with DT score was highlysignificant (B 5 2 0.02; CI (20.03; 2 0.01); P 5

3.1. Sample characteristics 0.0005) even after adjustment for sex, age andeducational level. A depressive temperament could

The sample was composed of 27 (37.5%) males therefore be considered predictive for an increasedand 45 (62.5%) females, with a mean age of 41.7 frequency of episodes, and for a depressive ratheryears (S.D. 13.9; range 19–77). than manic polarity of these episodes. Conversely,

Educational level was less than ‘baccalaureate’ elevated HT scores was associated with a strong( , 12 years of education) for 30 (41.7%) patients trend to have manic rather than depressive episodes.and equal to or more than ‘baccalaureate’ ( $ 12 Neither the type of the first episode, nor the age atyears of education) for 42 (58.3%) patients. The first hospitalization were associated with HT or DToccupational status was ‘unemployed’ or ‘disability temperament scales. In contrast, the history ofpension’ for 26 (36.1%) patients, and ‘currently suicide attempts was influenced by temperamentworking’, ‘student’ or ‘retired’ for 46 (63.9%) status since there was a significant association be-patients. Concerning marital status, 33 (45.8%) tween depressive scores and suicide attempts (OR 5

106 C. Henry et al. / Journal of Affective Disorders 56 (1999) 103 –108

Table 1Association between hyperthymic or depressive temperaments and clinical features of the manic-depressive illness: logistic or multipleregressions.

Association with Unadjusted Adjusted for age, sex, educationalalevel

Total number of episodesHyperthymic score B 5 2 0.05 p 5 0.02 B 5 2 0.03 p 5 0.07Depression score B 5 0.06 p 5 0.01 B 5 0.04 p 5 0.06

Percentage manic episodesHyperthymic score B 5 0.008 p 5 0.04 B 5 0.007 p 5 0.09Depression score B 5 2 0.02 p 5 0.0005 B 5 2 0.01 p 5 0.002

Type of first episodeHyperthymic score OR 5 1.01 p 5 0.70 OR 5 1.04 p 5 0.46Depression score OR 5 0.97 p 5 0.62 OR 5 0.94 p 5 0.38

Age at first hospitalizationHyperthymic score B 5 2 0.003 p 5 0.68 B 5 0.002 p 5 0.82Depression score B 5 0.007 p 5 0.43 B 5 0.0 p 5 0.92

History of suicide attemptHyperthymic score OR 5 0.88 p 5 0.02 OR 5 0.88 p 5 0.04Depression score OR 5 1.26 p 5 0.002 OR 5 1.16 p 5 0.003

bOccupational statusHyperthymic score OR 5 0.97 p 5 0.62 OR 5 0.99 p 5 0.84Depression score OR 5 0.96 p 5 0.61 OR 5 0.94 p 5 0.34

cMarital statusHyperthymic score OR 5 0.92 p 5 0.10 OR 5 0.95 p 5 0.35Depression score OR 5 1.08 p 5 0.18 OR 5 1.01 p 5 0.87

a, vs $ 12 years of education. The associations with occupational level were not adjusted for this variable.

b Unemployed/disability pension vs currently working, student or retired.c Always single vs other (married, divorced, widowed).

1.26; CI (1.09; 1.46); P 5 0.002). This association We have a priori chosen to consider temperamentsremained significant after adjustment for age, sex as dimensions rather than categories in order to avoidand educational level, and also after further adjust- arbitrary thresholds. Since this approach has not beenment for the percentage of depressive episodes. previously used, our results have to be cautiouslyFinally, no association was found between HT or DT compared to those of previous studies.scores and occupational or marital status. Assessment of temperaments was carried out when

patients had recovered, as confirmed by low scoreson the MADRS and Bech mania scales. It is there-

4. Discussion fore unlikely that the present findings may beexplained by state-dependent variables. In addition,

In this study of 72 patients with bipolar type I Klein (1990) showed longitudinal stability and a lackdisorder, we show that a high score on the DT score of thymic state-dependency with the depressiveis associated with a greater lifetime number of temperamentepisodes, a high percentage of major depressive Our results are consistent with data previouslyepisodes and a high history of suicide attempts. reported. Perugi et al. (1990) investigated possibleConversely, a high HT score is associated with a gender-mediated clinical expressions of depression,strong trend to have manic rather than depressive focusing on temperamental characteristics and theepisodes. Thus, our study shows a continuum be- longitudinal aspects of mood disorder. The incidencetween temperament and polarity of episodes and a of depressive episodes was higher in women, as wasbetter prognosis for patients presenting with more that of depressive temperament. By contrast, maleshyperthymic traits. had higher rates of hyperthymic temperament and

C. Henry et al. / Journal of Affective Disorders 56 (1999) 103 –108 107

hypomanic episodes. The sample for this study siblings of adults with bipolar affective disorder,included a low percentage of Bipolar I disorder, only hyperthymic and depressive temperaments were ob-5.4%, and the majority were patients with single or served before any superimposed episodes occurredrecurrent depressives episodes. For the authors, (Akiskal et al., 1985).temperamental differences might account for some of Strelau (1983) defined temperament as ‘the rela-the observed gender differences in the rates of tively stable features of the organism, primarilydepression and its subtypes. biologically determined, as revealed in the formal

Some studies have shown that temperaments traits of reactions which form the energy level andinfluence the incidence of mixed episodes. Indeed, temporal characteristics of behavior’. Klein et al.Dell’Osso et al. (1991) showed that mixed states are (1988) demonstrated dysthymia among the offspringmore likely to arise from a depressive temperament. of probands with major affective illness. Klein et al.This supports the Akiskal (1992) clinical observation (1985) also demonstrated the occurrence ofthat mixed states tend to arise when temperament cyclothymia among the adolescent offspring of bipo-and episodes are of opposing polarity. Dell’Osso et lar adults. Furthermore, among monozygotic twins ofal. (1991) concluded that the mixed state tends to patients with bipolar disorder who are not themselveshave a distinct longitudinal pattern of manic-depres- affected, over half suffer from temperamental distur-sive illness. Instead of postulating the existence of bances (Bertelsen et al., 1977). Thus, it could besuch a sub-category, we could also assume that this assumed that temperamental attributes would repre-pattern is underlied by the depressive temperament sent predisposing familial-risk factors for affectivewhich may influence the evolution and the clinical illness. Further investigations regarding comorbidity,picture. syndromal phenomenology, treatment response and

On the other hand, these temperamental differ- temperament in relatives are now required toences could explain why most studies on bipolar strengthen the hypothesis of a trait-state continuumpatients’ personality do not find differences when between personality and affective episodes, whichcomparing with control subjects (Hirschfeld and could both represent the expression of the sameKlerman, 1979; Liebowitz et al., 1979; Goodwin and genetic or constitutional endowment.Jamison, 1990). Most of these studies compareintroverted versus extroverted traits which are re-spectively very close to depressive and hyperthymic

Acknowledgementstemperaments. Given that bipolar patients represent avery heterogeneous group for drive, affect, and

ˆThis work was supported by a grant from Rhone-emotions, all of which define their temperament, andPoulenc Rorer (JL) and Assistance Publique.that these temperaments could be opposed, then the

negative results of these studies comparing medianvalues may be understood.

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