Temperament and character in euthymic major depressive disorder patients: the effect of previous suicide attempts and psychotic mood episodes.

Abstract

The purpose of this study was to examine personality traits of patients with major depressive disorder and explore the possible connections between personality and clinical and sociodemographic variables.
The sociodemographic and clinical properties of 80 patients with major depression, who were euthymic according to Hamilton Depression Scale scores, were recorded. Their personality was evaluated by using Temperament and Character Inventory and results were compared with 80 age- and sex-matched healthy controls. We used general linear model analysis to evaluate the manner in which the variables contributed to TCI scores.
Remitted depressive patients scored significantly lower on on self-directedness and higher on harm avoidance than HC. Previous suicide attempts had a main effect only on harm avoidance while previous psychotic mood episodes were significantly associated with novelty seeking, self-directedness and cooperativeness. With respect to numeric clinical variables, only duration of illness was significantly and negatively correlated with NS and RD scores.
Patients with euthymic major depressive disorder may have significantly different personality traits than the normal population, and patients with different clinical and sociodemographic characteristics may show different personality patterns. In addition, assessment of major depressed patients by means of the Temperament and Character Inventory may be helpful to get a deeper insight into those personality traits underlying suicidality and the emergence of psychotic mood episode.

Full text

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Copyright © 2012 Korean Neuropsychiatric Association 119
Temperament and Character in Euthymic Major Depressive
Disorder Patients: The Effect of Previous Suicide Attempts and
Psychotic Mood Episodes
Okan Ekinci1 , Yakup Albayrak2 and Aslı Erkan Ekinci1
1Department of Psychiatry, Yozgat State Hospital, Yozgat, Turkey
2Department of Psychiatry, Kırklareli State Hospital, Kırklareli, Turkey
ObjectiveaaThe purpose of this study was to examine personality traits of patients with major depressive disorder and explore the pos-
sible connections between personality and clinical and sociodemographic variables.
MethodsaaThe sociodemographic and clinical properties of 80 patients with major depression, who were euthymic according to Ham-
ilton Depression Scale scores, were recorded. Their personality was evaluated by using Temperament and Character Inventory and re-
sults were compared with 80 age- and sex-matched healthy controls. We used general linear model analysis to evaluate the manner in
which the variables contributed to TCI scores.
ResultsaaRemitted depressive patients scored significantly lower on on self-directedness and higher on harm avoidance than HC. Pre-
vious suicide attempts had a main effect only on harm avoidance while previous psychotic mood episodes were significantly associated
with novelty seeking, self-directedness and cooperativeness. With respect to numeric clinical variables, only duration of illness was sig-
nificantly and negatively correlated with NS and RD scores.
ConclusionaaPatients with euthymic major depressive disorder may have significantly different personality traits than the normal pop-
ulation, and patients with different clinical and sociodemographic characteristics may show different personality patterns. In addition,
assessment of major depressed patients by means of the Temperament and Character Inventory may be helpful to get a deeper insight
into those personality traits underlying suicidality and the emergence of psychotic mood episode. Psychiatry Investig 2012;9:119-126
Key Wordsaa Major depressive disorder, Personality, Suicide, Psychotic mood episode.
Received: August 8, 2011 Revised: December 14, 2011
Accepted: December 16, 2011 Available online: April 30, 2012
 Correspondence: Okan Ekinci, MD
Yozgat State Hospital, Psychiatry Department, Yozagt 66100, Turkey
Tel: +90-354-2121070, Fax: +90-354-2121071
E-mail: drokanekinci@yahoo.com
cc This is an Open Access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduc-
tion in any medium, provided the original work is properly cited.
INTRODUCTION
Major depression is a chronic and disabling disorder with
high rates of recurrence and depressive disorders are highly
prevalent worldwide.1 Personality features may predispose an
individual to depression; the personality can be modified af-
ter the onset of depressive episode; and the personality can
modify the clinical presentation of a depressive episode, and
also, depressive personality can be considered as a subtype of
a depressive disorder.2-4 In Cloninger’s psychobiologic model
of temperament and character, relationships between the st-
ructure and development of personality and psychiatric dis-
orders are described. This model postulates that personality is
comprehensively developed with respect to genetic traits, lear-
ning, and insight into the self-concept. The model is based on
4 temperament and 3 character dimensions. The tempera-
ment factors of harm avoidance, novelty seeking, reward de-
pendence, and persistence are considered to be biologically
based and highly heritable individual differences in habits
and skills. Character is a developmental construct consisting
of self-concept about the values and goals that influence the
significance of what is experienced. The character dimensions
self-directedness, cooperativeness, and self transcendence
mature in response to learning and life experiences and can
influence the expression of temperament.5,6
Studies using the TCI to investigate personality factors in
major depressive disorder (MDD) show consistent differences
between MDD and healthy comparison subjects (HC). Sub-
Print ISSN 1738-3684 / On-line ISSN 1976-3026
OPEN ACCESS
http://dx.doi.org/10.4306/pi.2012.9.2.119
ORIGINAL ARTICLE

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120 Psychiatry Investig 2012;9:119-126
Temperament and Character in Major Depressive Disorder
jects with MDD exhibit higher levels of harm avoidance and
self-transcendence and lower levels of self-directedness and
cooperativeness than HC.4,7,8 On the other hand, few studies
have compared the TCI profiles of euthymic MDD patients
and HC. These studies showed that remitted MDD patients
continue to show higher harm avoidance scores and lower
self-directedness scores compared to HC soon after the re-
mission of their depressive episode.7-9
However, to our knowledge, only one study has specifically
assessed the relationship between clinical features and tem-
perament and character traits in remitted MDD patients.9 The
major limitation of that study on patients with MDD was that
all patients were not euthymic and sample size of euthymic
patients was too small, because mood states may affect the re-
sults. In addition, depressed MDD patients exhibit a charac-
teristic cognitive bias as a result of their condition. This de-
pressive cognitive dysfunction might influence either the self-
reporting or the actual personality traits.5,10 Temperament and
character traits have been researched and considered as im-
portant factors for suicidal behavior in recent years.11 On the
other hand, previous research suggests that psychotic depres-
sive patients have a more severe and chronic form of illness
compared with those with non-psychotic major depression
(NMD). However, there is little information about the rela-
tionship between personality and psychotic mood episodes
although it is known that the personality can modify the clin-
ical presentation of a depressive episode.9,12 Therefore, we also
considered these clinical features as related factors when as-
sessing personality.
In this study, we sought to clarify the relationship between
personality, as measured by TCI, and MDD in euthymic
phase. We hypothesized that eutymic MDD patients demon-
strate a different personality profile compared to HC. Our an-
other hypothesis was that some clinical appearances such as
the history of suicide attempt and psychotic mood episode,
would be differentially related to personality profile in sub-
jects with remitted major depressive disorder.
METHODS
Subjects
This was a cross-sectional study. Four-hundred and forty-
six consecutive patients with a diagnosis of major depressive
disorder who were admitted in the period between April 2010
and January 2011 to our outpatient department, were prelimi-
narily screened for the study. The diagnoses were made by a
trained interviewer (AE) using the Structured Clinical Inter-
view for DSM-IV (SCID-P) and were confirmed through a
consensus meeting attended by two psychiatrists (including
OE and YA).13-16 All evaluations were made by three research-
ers. Clinical variables were collected by psychiatric interview
and by review of the patient charts and inpatient files. The
clinical state of patients was determined by the authors using
SCID for DSM-IV and the Hamilton Depression Rating Scale
(HDRS). All of the patients were in a state of remission at the
time of testing. Remission was defined as a period of at least 2
months during which the subject had no significant signs or
symptoms of the disorder (according to DSM-IV criteria) and
during which the HDRS were below 6. Inclusion criteria con-
sisted of being 18-55 years old and being in remission for 2
months (HDRS score <6). Subjects who had other disorders
that could have influence on cognitive function (significant
neurological and physical illness, substance abuse or depen-
dence in the last year, electroconvulsive therapy in the preced-
ing year, intoxication or cerebral trauma history), subjects
who had comorbid axis II disorder were excluded. The study
was reviewed and approved by our institutional review board.
Before study-specific procedures were carried out, the study
was thoroughly explained to subjects, and written informed
consent was obtained.
From the initial sample of four-hundred and forty-six ma-
jor depressive patients, one-hundred and seven patients were
enrolled to the study according to our remission criteria.
Among remitted depressive patients, 8 were excluded because
they were diagnosed with comorbid substance use disorders,
6 were excluded because of comorbid medical or neurological
illness, 13 were excluded because of comorbid axis II diagno-
sis. Thus, 80 consecutive remitted patients were included in
the final sample. In addition, 80 control subjects matched for
age, education and gender were tested. The control group
comprised healthy volunteers with similar socio-cultural
backgrounds to the patients. Controls were recruited from
the general population through advertisements asking for the
aid of unpaid volunteers. Controls were assessed by the HDRS.
Turkish versions of the Structured Clinical Interview for DSM
non-patients (SCID-NP) and SCID-II were also administered
to the control group.16,17 They did not have any current or life-
time axis I or II disorder. Controls conformed to the same ex-
clusion criteria as the participants with major depressive dis-
order. They also had no family history of major psychiatric
illness (psychosis, affective disorder, suicide or alcohol and
substance misuse) in a first-degree relative.
Clinical assessment
The 17-item version of the Hamilton Depression Rating
Scale (HDRS) was used to assess severity of depression.18,19
Personality was assessed using the Temperament and Charac-
ter Inventory (TCI) a 240-question self-report instrument.
The TCI (version IX) was also reported to be a valid and reli-
able instrument for Turkish healthy and psychiatric popula-

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O Ekinci et al.
www.psychiatryinvestigation.org 121
tions.20 According to Cloninger’s psychobiological model, the
temperament dimension Novelty Seeking (NS) is defined as a
tendency to respond to novelty, impulsiveness and quick loss
of temper and active avoidance to frustration. A second tem-
perament dimension, Harm Avoidance (HA) is viewed as a
bias in the inhibition of behaviors, such as pessimistic worry,
passive dependent behaviors and rapid fatigability. The third
temperament dimension, Reward Dependence (RD) is de-
fined as a bias toward the maintenance of ongoing behaviors
and is manifested in social attachment and dependence on
approval of others. Persistence (PE) is defined as a tendency
to perseverance despite frustration and fatigue. The character
dimension, termed Selfdirectedness (SD), refers to self-deter-
mination, self-esteem and to the ability of an individual to
control, regulate and adapt behavior to fit the situation in ac-
cord with personal goals and values. The second character di-
mension, Cooperativeness (CO), accounts for individual dif-
ferences in identification with and acceptance of other people
and measures aspects related to agreeability self-centered ag-
gression and hostility. Self-transcendence (ST) refers to spiri-
tual maturity, transpersonal identification and self-forgetful-
ness.
Data analysis
We used SPSS for Windows 16.0 version for all statistical
analyses in this study. A confidence interval of 95% and a
2-tailed p value less than 0.05 was considered statistically sig-
nificant for all analyses. Variables were tested for homogeneity
of variance by using the Levene test and for normality of dis-
tribution using the Kolmogorov-Smirnov test. Data that de-
parted significantly from normality of distribution or homo-
geneity of variance were analyzed nonparametrically. For a
comparison of sociodemographic characteristics of patients
and controls, χ2 test was used. Pearson’s correlation was per-
Table 1. Demographic and clinical characteristics of subjects with major depressive disorder and healthy comparison subjects
Major depressive disorder (N=80)
Age
Gender Female
Male
Occupation Unemployed
Worker
Officer
Retired
Housewife
Marital status Single
Married
Widowed
Smoking No
Yes
Length of education (years)
Socioeconomic levelLow
Medium
High
Family history of mental ilness No
Yes
Previous suicide attempt No
Yes
Previous psychotic mood episodeNo
Yes
Age at ilness onset
Duration of illness (years)
Number of hospitalisation
Number of depressive episodes
Number of psychotic mood episodes
**p<0.001. NA: not applicable
Healthy controls (N=80)
31.6±4.4
40 (50%)
40 (50%)
9 (1.9%)
27 (33.3%)
44 (64.8%)
0 (0.0%)
0 (0.0%)
17 (16.7%)
63 (83.3%)
0 (0.0%)
46 (70.4%)
34 (29.6%)
9.2±2.9
19 (24.2%)
21 (25.8%)
40 (50.0%)
-
p
36.8±6.9
50 (62.5%)
30 (37.5%)
4 (5.0%)
12 (15.0%)
21 (26.2%)
11 (13.8%)
27 (33.8%)
12 (15%)
62 (77.5%)
6 (7.5%)
50 (62.5%)
30 (37.5%)
8.9±2.2
13 (16.2%)
28 (35%)
39 (48.8%)
17 (21.2%)
63 (78.8%)
41 (51.2%)
39 (48.8%)
56 (70%)
24 (30%)
30.8±6.8
6.9±7.9
0.6±0.8
3.3±1.5
0.4±0.7
0.086
0.160
<0.001**
0.120
0.362
0.430
0.112
-
-
-
-
-
-
-

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122 Psychiatry Investig 2012;9:119-126
Temperament and Character in Major Depressive Disorder
formed to analyze the correlation coefficients between mood
state (scores of HAM-D), numeric clinical variables and TCI
scores. To determine the factors that have association with
TCI scores, first statistical analysis were performed by using
1-way analysis of variance with posthoc Tukey test and t test
for independent samples. A risk factor model was formed by
using these results, and these variables were used for second-
ary analysis. Secondary analysis involved a multivariate linear
regression analysis approach to analysis of covariance. Age
and the years of education were continuous variables; gender,
suicide history and previous psychotic mood episode were
dichotomous categorical predictor variables; and TCI scores
were dependent variables.
RESULTS
A total of 80 patients with MDD (50 women and 30 men)
and 80 healthy controls (40 women and 40 men) completed
the study. The mean age for patient groups was 36.8±6.9 years
and that for control group was 31.6±4.4 years. Two groups
were compared with regard to age, gender, education, occu-
pation, socioeconomic class and status of smoking. As shown
in Table 1, patients and controls did not differ significantly on
any of these features, except of the occupation.
The duration of illness was 6.9±7.9 years. The average age
of the first depressive episode experienced by the subjects was
30.8±6.8 years. The mean duration of remission was 5.07±
2.34 months for patient sample. The mean number of depres-
sive episodes, psychotic mood episodes and hospitalizations
were 3.3±1.5; 0.4±0.7 and 0.7±0.8, respectively. Among the
patients, 48.8% (n=39) made at least 1 suicide attempt and
30% (n=24) had at least 1 previous psychotic mood episode.
Mean and SD for HAM-D scores were 1, 82±0.61 for patients
sample and 0.25±0.44 for control sample.
Regarding temperament traits, the scores of harm avoid-
ance was substantially higher in subjects with depression than
in healthy comparison subjects. No significant differences
were found between the groups concerning novelty seeking,
reward dependence and persistence scores, as shown in Table
2. Regarding character traits, patients with MDD scored sig-
nificantly lower than healthy controls on the SD scores. No
significant differences were found between the groups con-
cerning self-transcendence and cooperativeness, as shown in
Table 2. We next investigated the role of education, age and
gender in these differences. We conducted GLM analyses with
age and education as continuous predictors and gender as a
categorical predictor, and TCI scores as dependent variables.
Gender significantly contributed to scores on HA and P (F=
4.63, df=2, p=0.03 and F=4.48, df=2, p=0.03, respectively).
Male participants scored significantly higher on HA and P
subscales of TCI (HA: 17.4±0.6 versus 15.6±0.5 t (132)=-2.7
p=0.008; p: 3.7±0.3 versus 2.9±0.2 t (132)=-2.17 p=0.032).
Age, education and the interaction of group and gender did
not significantly contributed to any TCI score (Table 3). In
addition, there was no effect of occupation on the differences
of temperament and character between two groups in multi-
variate analysis (F=1.63, df=14, p=0.07).
NS and RD scores had negative correlations with duration
of illness in subjects with MDD (n=80) (r=-0.247, p<0.05 and
r=-0.241, p<0.05, respectively). We did not find any signifi-
cant correlations between age, education, age at illness onset,
HDRS scores, number of hospitalizations, number of depres-
sive episodes, number of suicide attempts and psychotic
mood episodes, and any TCI score. In addition, there was no
significant correlation between duration of remission and any
TCI subscale in depressive subjects.
In the patient sample, we investigated effects of age and
years of education as continuous predictor variables, and gen-
der, previous suicide attempt and previous psychotic mood
episode as dichotomous categorical variables, on TCI scores.
The results, summarized in Table 4, showed that education,
age and gender did not significantly contribute to any TCI
Table 2. Temperament and Character Inventory (TCI) scores in subjects with major depressive disorder and in healthy comparison subjects
Major depressive disorder (N=80)
Temperament traits
Harm avoidance 18.18±3.83
Novelty seeking 21.32±4.72
Reward dependence 9.60±3.10
Persistence 3.21±1.66
Character traits
Self-directedness24.69±7.12
Cooperativeness26.82±5.57
Self-transcendence 14.55±4.61
**p<0.001
Healthy controls (N=80)tp
11.45±5.04
21.66±3.29
10.28±2.44
3.44±2.44
t=-4.61, df=132
t=-0.461, df=132
t=-1.34, df=132
t=-0.656, df=132
<0.001**
0.645
0.180
0.513
36.16±6.91
24.11±4.58
16.0±4.84
t=4.445, df=132
t=1.87, df=132
t=-1.75, df=132
<0.001**
0.063
0.082

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O Ekinci et al.
www.psychiatryinvestigation.org 123
score. Previous suicidal attempt significantly contributed to
HA scores while previous psychotic mood episode signifi-
cantly related to NS, SD and CO scores. HA was significantly
higher in subjects with depression who had made suicide at-
tempts than in those who had not (22.2±2.01 versus 14.9±4.5;
t (78)=9.29, p<0.001). The subjects with depression who had
experienced psychotic mood episode scored significantly
higher on NS and significantly lower on CO and SD subscales
of TCI than those who had not (t=-3.241, df=78, p=0.002;
t=4.414, df=78, p<0.001 and t=8.436, df=78 p<0.001, respec-
tively). In addition, there was no effect of the interaction be-
tween suicidal attempt and psychotic mood episode on TCI
scores.
DISCUSSION
Present study mainly demonstrated that euthymic MDD
patients present a different personality profile than HC, with
higher scores on harm avoidance and lower scores on self-di-
rectedness. In addition, MDD patients with suicide attempts
exhibited higher HA scores while those experienced at least
one psychotic mood episode significantly scored higher on
NS and lower on CO and SD than those without these fea-
tures. With respect to numeric clinical variables, duration of
illness was significantly and negatively correlated with NS and
RD scores. In the present study, we used clear and rigorous
remission criteria when assessing our subjects and the study
sample comprised of only remitted depressive patients. Our
sample size was relatively larger than remitted patient group
in the study of Nery et al.9 In addition, another limitation of
their study is that the authors did not consider important
clinical features such as suicidality and presence of psychotic
mood episode when assessing personality.
Our findings confirm prior reports of higher HA scores
among MDD subjects compared with healthy controls. Previ-
ous studies found results similar to ours, i.e., higher harm
avoidance and lower self-directedness in MDD patients com-
pared to HC.4,7,8,21 Harm avoidance, defined as a tendency to
respond intensely to signals of aversive stimuli, thereby learn-
ing to avoid punishment and novelty appears to be a measure
that is elevated during depressive states.22,23 There is evidence
for a state dependency of personality traits as measured by the
TCI, in particular a decrease in harm avoidance as depression
improves. Moreover, Mulder and Joyce23 have reported a sig-
nificant difference between HA scores assessed initially and
after 6 weeks of antidepressant treatment.
In the present study, HA scores were measured in only re-
mitted MDD patients and HC. Also, it is possible that higher
Table 3. Temperament and Character Inventory (TCI) scores in subjects with major depressive disorder versus comparison subjects: effect
of age, gender, and education
HA NS RD
Current age1.87 (0.17)0.02 (0.88)0.15 (0.69)
Gender
4.63 (0.03)
2.58 (0.11)0.38 (0.54)
Length of education0.58 (0.45)0.03 (0.86)0.15 (0.70)
Group
20.04 (0.00)
0.71 (0.402) 0.81 (0.37)
Group X gender 0.15 (0.67)2.60 (0.11) 0.32 (0.57)
Table shows F ratios from general linear model analysis; F df=1. Current age and years of education were continuous variables; group and
gender were dichotomous categorical predictor variables; and TCI scores were dependent variables. p values of F ratios are in parentheses.
Significant F ratios are shown in bold type. TCI: Temperament and Character Inventory, HA: harm avoidance, NS: novelty seeking, RD: re-
ward dependence, P: persistence, SD: self-directedness, ST: self-transcendence, CO: cooperativeness
pSD STCO
0.39 (0.53)
4.48 (0.03)
3.19 (0.08)
0.001 (0.98)
0.001 (0.98)
0.11 (0.74)
0.006 (0.94)
1.78 (0.18)
18.57 (0.00)
2.08 (0.15)
0.11 (0.74)
0.33 (0.56)
0.01 (0.93)
2.44 (0.12)
0.08 (0.78)
0.205 (0.74)
0.30 (0.585)
0.45 (0.501)
3.56 (0.06)
0.51 (0.47)
Table 4. Relationships between TCI scores and sociodemographic and clinical features in subjects with major depressive disorder
HANS
Age 2.87 (0.09)0.62 (0.43)
Gender 0.88 (0.35)3.63 (0.06)
Length of education0.03 (0.85) 1.44 (0.23)
Previous suicide attempt
42.36 (0.00)
3.59 (0.06)
Previous psychotic mood episode2.95 (0.09)
8.98 (0.004)
Previous suicide attempt X previous
psychotic mood episode
Table shows F ratios from general linear model analysis; F df=1. Current age and years of education were continuous variables; suicide histo-
ry, previous psychotic mood episode and gender were dichotomous categorical predictor variables; and TCI scores were dependent variables.
p values of F ratios are in parentheses. Significant F ratios are shown in bold type. TCI: Temperament and Character Inventory, HA: harm
avoidance, NS: novelty seeking, RD: reward dependence, P: persistence, SD: self-directedness, ST: self-transcendence, CO: cooperativeness
RDpSDSTCO
0.09 (0.76)
0.87 (0.35)
0.02 (0.89)
0.01 (0.94)
0.84 (0.36)
3.52 (0.07)
1.21 (0.276)
1.64 (0.204)
0.72 (0.401)
0.06 (0.81)
7.41 (0.008)
0.01 (0.757)
1.22 (0.27)
2.13 (0.15)
2.09 (0.15)
1.65 (0.20)
37.4 (0.00)
0.03 (0.87)
0.12 (0.73)
0.51 (0.48)
0.15 (0.69)
1.36 (0.25)
1.98 (0.16)
0.02 (0.89)
0.76 (0.38)
0.13 (0.71)
0.47 (0.49)
1.52 (0.22)
8.62 (0.004)
0.21 (0.65)1.88 (0.17)0.12 (0.72)