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Hyperthymic and cyclothymic temperaments: Attenuated forms of bipolar disorder?
Abstract
A temperament is described as a temporally stable dimension, biologically determined. Several temperaments have been described (hyperthymic, depressive, cyclothymic, irritable and anxious) and could represent premorbid characteristics of an affective disorder. Some temperaments could thus correspond to chronic sub-affective states expressed as attenuated forms of mood disorder. Several studies suggest that a large proportion of bipolar patients have a hyperthymic or cyclothymic temperament. Moreover, temperaments seem to influence the clinical caracteristics of bipolar disorders. Future investigations will evaluate whether temperaments represent a predisposing factor, an attenuated form of bipolar disorders or a distinct entity.
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IntroductionRecent research postulated that temperaments represent the subclinical foundations of affective disorders, and an early clue for a recurrent, prebipolar disorder. Akiskal et al. operationalized five types of temperaments: depressive, hyperthymic, irritable, cyclothymic and anxious. The aims of this study were to compare the affective temperaments scores in patients with bipolar I, II and recurrent depression disorders and to explore the relation between temperaments scores and clinical features of those affective disorders.Methods
This was a comparative cross-sectional study, concerning three groups: patients with bipolar I disorder (BIP I) (n = 31, 20 men and 11 women, mean age = 42.0 ± 10.1 years), patients with bipolar II disorder (BIP II) (n = 18, 11 men and seven women, mean age = 40.7 ± 10.8 years) and patients with recurrent depressive disorder (RDD) (n = 66, 28 men and 38 women, mean age = 45.0 ± 9.3 years). All patients were in remission of a major depressive episode. The affective temperaments were assessed by the Akiskal and Mallya Affective Temperament questionnaires.ResultsHyperthymic temperament mean scores were higher in BIP I (10.8 ± 5.4) and BIP II (10.3 ± 5.5) groups compared to RDD group (5.5 ± 4.0) (p < 10−3). Depressive temperament mean score was significantly higher in RDD group (10.5 ± 4.3), compared to BIP I (7.3 ± 4.6) and BIP II (5.4 ± 2.9) groups (p < 10−3). Cyclothymic temperament mean score was higher in BIP II group (4.7 ± 5.8) compared to BIP I (3.3 ± 3.9) and RDD (2.5 ± 3.9) groups, but this difference was not significant (p = 0.08). No difference was found between the three groups concerning irritable temperament scores.Negative correlation was found between hyperthymic and depressive temperament scores in BIP I (r = −0.81, p < 0.001) and RDD (r = −0.73, p < 0.001) groups, but not in BIP II group.Concerning the clinical correlates with affective temperament scores, negative correlation was found between hyperthymic temperament score and number of depressive episodes in BIP II group (r = −0.53, p = 0.02). Hyperthymic temperament score was associated with psychotic features in the last depressive episode in BIP I (p = 0.01) and BIP II (p = 0.008) groups and seasonal features in BIP II group (p = 0.02). Moreover, cyclothymic temperament score was associated with psychotic (p = 0.009) and seasonal features (p = 0.03) in BIP II group.Conclusions
Despite the small sample sizes for our study groups, we can conclude that hyperthymic and cyclothymic temperaments characterized bipolar disorders and are correlated with other markers of bipolarity such as psychotic and seasonal features. Thus, temperament assessment might become a useful tool to predict bipolarity in association with those markers.
The prognostic significance of affective temperaments in bipolar disorder is not yet fully understood. This study therefore examined the relationship between affective temperaments and two major illness outcomes in bipolar disorder: functional impairment and affective recurrences.
At baseline fifty-one remitted bipolar disorder patients were administered the Temperament Evaluation of the Memphis, Pisa, Paris and San Diego Auto-questionnaire (TEMPS-A), and the Work and Social Adjustment Scale (WSAS). The patients were followed for 24 months as part of their routine treatment. At follow-up, data on affective recurrences were obtained through medical records combined with a semi-structured interview that enquired into medication adherence.
Scores on the cyclothymic temperament correlated significantly with functional impairment overall and with scores in three function domains: home-management, private leisure activities and social leisure activities. High scores on the cyclothymic temperament also significantly predicted the presence of depressive recurrences even when controlling for medication non-adherence. The presence of hypomanic or manic recurrences was not predicted by scores on any of the affective temperaments.
Since all of the bipolar patients were newly diagnosed and therefore relatively young, the representativeness of the results may have been reduced. The prospective part of the study used data from medical records that may not be as systematic as data gathered from structured clinical interviews.
By suggesting that the cyclothymic temperament is related to both functional impairment and depressive recurrences the findings highlight a vulnerability area in need of further exploration in terms of its prognostic significance.
Over the last three decades, cyclothymia has been positioned in one of two principal ways: formally classified as a mood disorder, and less formally categorized at a "cyclothymic temperament" (CT) level. This review considers its historic evolution and provides five models for conceptualizing independence or interdependence between cyclothymia as a temperament style and as a formal mood disorder. Findings argue for CT to be conceded and appropriately defined. Secondly, it is recommended that cyclothymia's expression as a mood disorder should be positioned within the bipolar II disorder class-albeit perhaps having briefer mood swings and fewer episodes, more rapid cycling, and greater reactivity to environmental factors than is conceptualized currently for bipolar II disorders. By allowing cyclothymia both axis I and axis II status (although necessitating differing terminology), research evaluating any shared biological underpinnings and any predisposition provided by the CT temperament style to a later formalized bipolar II condition would be advanced.
Previous research has examined the association of affective temperaments, as measured by the TEMPS-A, with DSM bipolar disorders. However, the relation of the TEMPS-A with risk for bipolar disorder remains unclear. The present study examined the association of affective temperaments with psychopathology, personality, and functioning in a nonclinically ascertained sample of young adults at risk for bipolar disorder.
One hundred forty-five participants completed the TEMPS-A, as well as interview and questionnaire measures of psychopathology, personality, and functioning.
Cyclothymic/irritable temperament was associated with a range of deleterious outcomes, including mood disorders and impaired functioning. It was negatively associated with agreeableness and conscientiousness, and positively associated with current depressive symptoms, neuroticism, borderline symptoms, impulsivity, and grandiosity. Dysthymic temperament was positively associated with current depressive symptoms, neuroticism and agreeableness, but was unrelated to mood psychopathology. Hyperthymic temperament was associated with bipolar spectrum disorders, hypomania or interview-rated hyperthymia, extraversion, openness, impulsivity, and grandiosity.
The present study was cross-sectional. Longitudinal studies utilizing the TEMPS-A are needed to better understand the predictive validity of the TEMPS-A for the development of bipolar disorder.
Early identification of individuals who fall on the bipolar spectrum may hasten appropriate intervention or monitoring, and prevent misdiagnosis. The TEMPS-A appears to be a useful tool for assessing affective temperaments and bipolar spectrum psychopathology. The results support previous research documenting the association of cyclothymic/irritable temperament with bipolar psychopathology and other negative outcomes.
Several studies show an association between the Hypomanic Personality scale (HPS; Eckblad & Chapman, 1986) and variables related to bipolar disorders. In theory, people with a hypomanic temperament are thought to be more active than others. The purpose of this study was to examine empirically which kinds of activities students with a hypomanic temperament typically pursue outside of the school context and especially how much time they engage in these activities. We hypothesized that students would report a high proportion of activities that are fun- and reward-related, also including problematic ones (e.g. alcohol abuse). Teenage students (n=4045) completed several questionnaires, including the HPS, CES-D, questions about performance in school, future success, and leisure activities. Using the HPS, a high-risk group (n=300) was defined and compared to a control group (n=1709). As hypothesized, “hypomanic” adolescents spent most of their time outside of school socializing with friends and pursuing sports rather than attending to duties such as homework, smoked more often, drank alcohol more often, and were more often involved in physical fights. The results are discussed within the context of a model that regards dysregulation of the Behavioral Activation System as a vulnerability factor in bipolar disorders.
Converging lines of evidence have established a relationship between exposure to ambient light and both mood state and mood disorders. In view of the association between mood disorder and affective disposition, in this study, the relationship between temperament (depressive, cyclothymic, hyperthymic, irritable and anxious) and daily light exposure was closely examined.
Fifty-six subjects completed the Japanese standardized version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto questionnaire version (TEMPS-A) and illuminance of daytime using actigraphy.
Cyclothymic temperament scores were significantly and negatively associated with illuminance of daytime whereas hyperthymic temperament scores were significantly and positively associated with illuminance of daytime.
Sample size was relatively small and they were only healthy subjects and no patients.
The findings suggest that illuminance of daytime may be related to both cyclothymic and hyperthymic temperaments but that the associations lie in opposite directions. If this is the case, it seems important to consider individual patients' temperaments when light therapy is used to treat their depressive episode. Further studies are required to determine why and how these temperaments are associated with illuminance.
The aim of this study was to investigate the characteristics of affective temperaments in general non-clinical population in different countries
We performed a detailed search of published studies (one unpublished) investigating affective temperaments in non-clinical populations by administering the Temperament Evaluation of Memphis, Paris and San Diego Auto-questionnaire (TEMPS-A) in its 110-items version. We have included a total of six studies published from different countries (Argentina, Germany, Hungary, Korea, Lebanon, and Portugal) and one unpublished with preliminary data from Spain. We analyzed the combined data from the collected studies.
We found significant gender differences, with men scoring higher in irritable and hyperthymic, and women in anxious, depressive and cyclothymic temperaments. Age had a significant effect in women with depressive temperament. Correlations among temperament scores have shown positive associations between depressive and anxious, and cyclothymic and irritable.
There was a similarity in gender differences and the association between different affective temperaments. Our results indicate that affective temperaments show both universal and distinctive characteristics.
The sample populations in different countries were not homogeneous for age and socio-economic composition. In the Korean study of Kang et al. the version of the TEMPS was not validated.
Hyperthymic temperament is one of several premorbid temperaments putatively associated with bipolar disorder. Several reports suggest that depressive patients with hyperthymic temperament may belong to the proposed soft bipolar spectrum.
To investigate biological aspects of hyperthymic temperament, the present study examined daily activity, sleep time, central serotonergic function, and other relevant variables in relation to hyperthymic temperament in healthy subjects.
Fifty six healthy subjects were monitored via the actigraphy system to measure daily total activity, sleep time, and illuminance. A neuroendocrine challenge test was performed to estimate central serotonergic function.
Multiple regression analysis revealed that higher illuminance of daytime, greater fluctuation in sleep time, and lower central serotonergic function significantly and independently predicted hyperthymic temperament scores.
The present findings suggest that light, sleep, and serotonin are crucial factors in understanding hyperthymic temperament, which may be common to bipolar disorder.
The concept of soft bipolar spectrum has not been fully confirmed. The aim of the present study is to investigate the validity of bipolar II1/2 and IV concept.
The subjects were 46 consecutive outpatients. The individual temperament of each patient was recorded using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A). The operational definition of bipolar II1/2 was those who had depression with cyclothymic temperament and that of bipolar IV was those who had depression with hyperthymic temperament. Finally, drug responses were investigated.
DSM-IV-TR diagnoses were bipolar I (N=1), bipolar II (N=9), major depressive disorder (N=34) and depressive disorder not otherwise specified (N=2). Excluding one bipolar I patient, who had both cyclothymic and hyperthymic temperaments, patients with bipolar II1/2 (N=32) and IV (N=13) as well as bipolar II (N=9) were classified into the soft bipolar spectrum, although there was considerable overlap. The categorization of soft bipolar spectrum and unipolar depression significantly predicted depressive, cyclothymic, irritable, and anxious temperaments. Moreover, soft bipolar spectrum patients with lithium treatment were significantly more in remission than those without lithium treatment. In addition, more of those with selective serotonin reuptake inhibitors (SSRIs) had a significant tendency to lower remission than those without SSRIs.
This is a cross-sectional study with a relatively small number of subjects.
The present findings suggest that cyclothymic and hyperthymic temperaments may predict bipolarity, and the validity of bipolar II1/2 and IV concept is supported.
The aim of this study was to investigate the role of hyperthymic temperament in suicidal ideation between a sample of patients with affective disorders (unipolar and bipolar).
We investigated affective disorders outpatients (unipolar, bipolar I, II and NOS) treated in eleven participating centres during at least a six-month period. DSM-IV diagnosis was made by psychiatrists experienced in mood disorders, using the corresponding modules of the Mini International Neuropsychiatric Interview (MINI). In addition, bipolar NOS diagnoses were extended by guidelines for bipolar spectrum symptoms as proposed by Akiskal and Pinto in 1999. Thereby we also identified NOS III (switch by antidepressants) and NOS IV (hyperthymic temperament) bipolar subtypes. All patients completed the Beck Depression Inventory (BDI). We screened a total sample of 411 patients (69% bipolar), 352 completed all the clinical scales without missing any item.
No statistical significant difference in suicidal ideation (measure by BDI item 9 responses) was found between bipolar and unipolar patients (4.5% vs. 9.1%, respectively). On the group of bipolar patients, suicidal ideation was slightly more frequent among bipolar NOS compared with bipolar I and II (p value 0.094 and 0.086, respectively), interestingly we found a statistical significant less common suicidal ideation among bipolar subtype IV (with hyperthymic temperament) compared with bipolar NOS patients (p value 0.048).
Our results indicate that those subjects with hyperthymic temperament displayed less suicidal ideation. This finding supports the hypothesis that this particular affective temperament could be a protective factor against suicide among affective patients.
The original objective of the national study was the cross validation between MDQ and BSDS in patients with affective disorders in our country. This report arises from a secondary analysis of the original data.
The present study was designed to investigate the relations between temperament and outcome in bipolar illness.
Seventy-two patients presenting with bipolar type I disorder were recruited from consecutive admissions and 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 hyperthymic temperaments (HT) in a dimensional approach.
Multiple regression analysis showed that a higher DT score or a lower HT score were significantly associated with a greater number of episodes. Furthermore, a higher DT score was strongly associated with a higher percentage of major depressive episodes. Conversely, a higher HT score was associated with a trend to manic rather than depressive episodes. Suicide attempts appeared more frequent in the history of patients presenting with higher DT scores.
Our findings strengthen the hypothesis that temperament is one of the main variables 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.
The present investigation focused on symptomatological subtypes of mania and their relationships with affective temperaments and other clinical features of bipolar disorder. In 153 inpatients with mania diagnosed according to DSM-III-R, symptomatological subtypes have been investigated by means of principal component factor analysis of 18 selected items of the Comprehensive Psychopathological Rating Scale (CPRS). We compared other clinical features, depressive and hyperthymic temperamental attributes, and first degree-family history for mood disorders among the various manic subtypes on the basis of the highest z-scores obtained on each CPRS factor (dominant CPRS factor groups). Five factors--Depressive, Irritable-Agitated, Euphoric-Grandiose, Accelerated-Sleepless, Paranoid-Anxious--emerged, accounting for 59.8% of the total variance. When the factor-based groups were compared, significant differences emerged in terms of the duration of the current episodes, rates of chronicity and incongruent psychotic features--being highest in the 'Depressive' and 'Paranoid-Anxious' dominant groups. The patients with highest z-scores for the 'Euphoric-Grandiose', 'Paranoid-Anxious' and 'Accelerated-Sleepless' factors were those most likely to belong to the hyperthymic temperament, while the 'Depressive' dominant group had the highest rate of depressive temperament. Finally, it is noteworthy that the 'Irritable-Agitated' group was high for both temperaments. The foregoing multidimensional structure of mania--revealing five factors--is generally concordant with the emerging literature. Consistently with our original hypothesis, a hyperthymic temperament seems to underlie the most extreme manic excitement with euphoric-accelerated-paranoid phenomenology. By contrast, the depressive temperament seemed to mute the expression of mania into a depressive-manic phenomenology.
The modern concept of affective disorders focuses increasingly on the study of subthreshold conditions on the border of manic or depressive episodes. Indeed, a spectrum of affective conditions spanning from temperament to clinical episodes has been proposed by the senior author. As bipolar disorder is a familial illness, an examination of cyclothymic temperament (CT) in controls and relatives of bipolar patients is of major relevance.
We recruited a total sample of 177 healthy symptom-free volunteers. These controls were divided into three groups. The first one is comprised of 100 normal subjects with a negative familial affective history (NFH); the second of 37 individuals, with positive affective family history (PFH); and a third of 40 subjects, with at least one sib or first-degree kin with bipolar disorder type I according to the DSM-IV (BPR). The last two groups defined at risk individuals. We interviewed all subjects with CT, as described by the senior author.
We found a statistically significant difference in the rates of CT between the subjects in BPR versus others. CT was also more prevalent in the PFH compared with NFH. Additionally, the simple numeration of the CT traits exhibited gradation in the distribution of individuals inside the NFH, PFH and BPR. Finally, categorically defined CT and CT traits predominated in females. LIMITATION and
Although not all relatives of bipolar probands were studied, our results exhibit an aggregation of CT in families with affective disorder-and more specifically those with bipolar background. These results allow us to propose the importance of including CT for phenotypic characterization of bipolar disorder. Furthermore, our results support a spectrum concept of bipolar disorder, whereby CT is distributed in ascending order in the well-relatives of those with depressive and bipolar disorders. We submit that this temperament represents a behavioral endophenotype, serving as a link between molecular and behavioral genetics.
Temperaments in bipolar subjects, as observed by Kraepelin and later re-dynamized and operationalized by Akiskal, have given rise to various studies, which results are hereby synthesized. In the light of these studies, the evaluation of temperaments allows to define subgroups of bipolar subjects, in order to sharpen diagnosis and therefore be able to propose more accurate treatment. A depressive temperament is linked to more frequent thymic relapses, on a depressive slope and it is associated with more frequent comorbid anxiety disorder and with an increased suicidal risk. A hyperthymic temperament is linked to manic relapses and is more likely to switch mood when patients were treated with antidepressants. A thymic episode that appears in a temperament of the opposite polarity will result in a mixed episode. Temperament evaluation is also helpful in choosing drug treatments. Practical clinical benefits can be gained from the study and analysis of those temperaments. As a further development, it could be useful to characterize euthymic period by a dimensional approach.