Temperament and Character Traits in Patients With Epilepsy Epileptic Personality

Article (PDF Available)inThe Journal of nervous and mental disease 201(5) · April 2013with492 Reads
DOI: 10.1097/NMD.0b013e31828e0e3d · Source: PubMed
  • 27.4 · Sakarya University
  • 23.64 · Sakarya University
  • 35.78 · Bakirkoy Prof.Dr.Mazhar Osman Mental and Neurological Diseases Education and Research Hospital; formerly Ataturk University, Medical Faculty
  • 28.3 · Ataturk University
Abstract
Personality and behavioral changes in epilepsy are well documented. However, neither the quantitative characteristics nor the etiology of these changes is clear yet. Cloninger has developed a psychobiological personality model that provides a way to evaluate personality in a dimensional way. This study examined the relationship between epilepsy and Cloninger's dimensional psychobiological personality model. A total of 73 epilepsy outpatients and 79 healthy controls were examined using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders, the Turkish version of the Temperament and Character Inventory, and an epilepsy questionnaire. Epilepsy patients had higher harm avoidance (HA) and lower persistence, self-directedness (SD), and cooperativeness scores than healthy controls did. In epileptic subjects, there was no correlation between age and duration of epilepsy. Subjects with partial seizures had higher HA scores and lower SD scores than generalized ones. Comorbid depression was represented with lower SD scores. In multiple linear regression models, only major depressive disorder predicted lower scores of SD. This study confirms specific personality changes among epileptics according to Cloninger's dimensional personality model and indicates a relationship between the characteristics of epilepsy and psychiatric comorbidity.
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Affective Temperaments in Epilepsy
Esra Yazici
1
, Ahmet Bulent Yazici
2
, Nazan Aydin
3
, Asuman Orhan Varoglu
4
, Ismet Kirpinar
5
ÖZET:
Eplepsde affektf mzaç özellkler
Amaç: Eplepsde özellkle depresyon olmak üzere sık-
lıkla görülen duygudurum bozuklukları (DDB), hastalığın
takp, tedav ve seyr açısından olumsuz sonuçlara neden
olablmektedr. Duygudurum bozukluklarının etyolojs
araştırılmaya devam edlmekte olup, rsk grupları tanım-
lanmaya çalışılmaktadır. Affektf mzaç özellkler günü-
müzde duygudurum bozukluğunun öncüller olarak
düşünülmektedr. Bu çalışmada affektf mzaç özellkle-
rnn eplepsl hastalarda duygudurum bozukluğunun
muhtemel öngördürücüsü olup olmadığını ncelemey
amaçladık. Böylece epleps-duygudurum bozuklukları
komorbdtesne yaklaşım cn öncül parametreler belr-
lemek üzere br adım oluşturmayı hedefledk.
Yöntem: 73 eplepsl hasta ve 79 sağlıklı kontrol bu
çalışmaya dahl edlmş daha sonra Memphs, Psa, Pars
ve San Dego Mzaç Değerlendrme Anket’nn Türkçe
formu (TEMPS-A) ve SCID-I formları kullanılarak hastalar
değerlendrlmştr.
Bulgular: Epleps hastaları hpertmk mzaç harç tüm
affektf mzaç özellklernde yüksek puanlara sahptler.
Eplepsl hastalarda anksyöz ve rrtabl mzaç daha
yüksek oranda gözlenmştr ve anksyöz mzaç major
depresf bozukluk (MDB) le bağlantılı bulunmuştur.
Epleps grubunda 14 hastaya kontrol grubunda se 6
hastaya MDB tanısı konuldu. Anksyöz mzaç eplepsl
hastalarda MDB çn öngördürücü olarak tespt edld.
Sonuç: Epleps hastalarında duygudurum bozukluğu-
na eğlm olduğu blnmekteyd ancak bu çalışmada lk
defa epleps hastalarında ‘affektf mzaç’a eğlm oldu-
ğu gösterlmştr. Eplepsde başta depresyon olmak
üzere duygudurum bozuklukları sıklıkla komorbd
olarak görülmekte olup hastalığın seyrn ve tedav-
sn olumsuz olarak etkleyen br durum olarak karşı-
mıza çıkmaktadır. Epleptk olan kşlerde duygudurum
bozukluğunun öngördürücülernn belrlenmes rskl
gruplara özel br yaklaşımı ve prognozun daha y olma-
sını sağlayablr.
Anahtar sözcükler: Epleps, affektf mzaç, depresyon,
duygudurum bozuklukları
Kl nk Pskofarmakoloj Bülten 2012;22(3):254-61
ABS TRACT:
Affective temperaments in epilepsy
Objective: Mood disorders (MDs), particularly
depression, are often encountered in epilepsy and may
negatively affect the treatment and prognosis of the
disease. Investigations into the etiology of MDs and the
qualities of at-risk groups have revealed that affective
temperament characteristics are antecedents of MDs.
In this study, our objective was to investigate whether
affective temperament characteristics were predictors
of MDs in epilepsy patients. Thus, we aimed to establish
a first step to determine preliminary parameters for an
approach to the comorbidity of epilepsy and MDs.
Methods: In total, 73 epilepsy patients and 79 healthy
controls were included in this study. The participants
were evaluated using the Turkish version of the
Temperament Evaluation of Memphis, Pisa, Paris, and
San Diego Autoquestionnaire (TEMPS-A) and the
Structured Clinical Interview of DSM Disorders (SCID-I).
Results: Epilepsy patients produced high scores in
all affective temperament characteristics except
hyperthymic temperament. Anxious and irritable
temperaments were observed more frequently in
epilepsy patients, and anxious temperament was found
to be associated with major depressive disorder (MDD).
Fourteen participants in the epilepsy group and 6
participants in the control group were diagnosed with
MDD. Anxious temperament was determined to be a
predictor of MDD.
Conclusion: Although it has been shown previously
that epilepsy patients tend to suffer from MDs, for the
first time, this study has demonstraed that epilepsy
patients also tend to have affective temperaments.
MDs, particularly depression, are frequently observed
in epilepsy patients as comorbid disorders, and they
have an adverse effect on epilepsy treatment and
prognosis. Determining the predictors of MDs in
epilepsy patients may improve the current approach
toward at-risk groups and lead to better prognoses.
Key words: Epilepsy, affective temperament,
depression, mood disorders
Bulletin of Clinical Psychopharmacology 2012;22(3):254-61
This study was presented as a
preliminary study at EPA-2010-Munich-
Germany as a proceeding.
1
M.D., Service of Psychiatry, Derince
Training and Research Hospital,
Kocaeli - Turkey
2
M.D., Department of Psychiatry, Kocaeli
Seka State Hospital, Kocaeli - Turkey
3
M.D., Department of Psychiatry, School
of Medicine, Atatürk University,
Erzurum - Turkey
4
M.D., Department of Neurology,
Selçuklu School of Medicine, Selçuk
University, Konya - Turkey
5
M.D., Department of Psychiatry, School
of Medicine, Bezmialem University,
İstanbul - Turkey
Ya zış ma Ad re si / Add ress rep rint re qu ests to:
Dr. Esra Yazıcı, Service of Psychiatry,
Derince Training and Research Hospital,
Kocaeli - Turkey
Telefon / Phone: +90-262-317-8000
Elekt ro nik pos ta ad re si / E-ma il add ress:
dresrayazici@yahoo.com
Gönderme tarihi / Date of submission:
1 Mayıs 2012 / May 1, 2012
Kabul tarihi / Date of acceptance:
31 Temmuz 2012 / July 31, 2012
Bağıntı beyanı:
E.Y., A.B.Y., N.A., A.O.V., I.K.: Yazarlar bu
makale ile ilgili olarak herhangi bir çıkar
çatışması bildirmemişlerdir.
Declaration of interest:
E.Y., A.B.Y., N.A., A.O.V., I.K. : The authors
reported no conflict of interest related to
this article.
Araştırmalar / Original Papers
DOI: 10.5455/bcp.20120731060406
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E. Yazici, A. B. Yazici, N. Aydin, A. O. Varoglu, I. Kirpinar
INTRODUCTION
Mood disorders (MDs), particularly depression, are
frequently observed in epilepsy patients (1) and have a
negative effect on the treatment and prognosis of epilepsy,
requiring an integrated approach (2). Identifying
individuals at risk of MDs may enable an earlier and
different approach to epilepsy patients with comorbid
disorders. It has been shown that MDs, especially
depression, are seen in epilepsy more frequently than other
chronic diseases and have a negative effect on the patient’s
adaptation to treatment, frequency of seizures, and quality
of life, and increase the risk of suicide. Furthermore,
epilepsy patients often do not mention depressive
symptoms, and depression can be overlooked in such
patients. This indicates the necessity of a more sensitive
approach to MDs in epilepsy patients (3-5).
Genetic, biological, and psychosocial approaches dfor
identifying the etiology of MDs and at-risk groups exist.
Akiskal claims that affective temperaments form the basis
of MDs and defines five main affective temperaments (6)
in a model aimed at identifying individuals at risk of MDs
(7-11). It has recently been determined that depressive
temperament is associated with frequent, recurrent, and
severe depression that begins early; hyperthymic
temperament is associated with bipolar disorder; and
cyclothymic temperament is associated with early onset
depression (12, 13). Genetic studies suggest that familial
transmission of affective temperaments may occur (14).
This study investigated affective temperament
characteristics and related factors with the intention of
shedding light on the evaluation of at-risk groups and the
probable common etiology for epilepsy–MD comorbidity.
MATERIALS AND METHODS
This study was carried out on outpatients diagnosed
with epilepsy at the Epilepsy Clinic in the Neurology
Department of a university hospital. All participants, who
signed written informed consent, were chosen sequentially,
and the ones meeting exclusion criteria were excluded.
The study was approved by the Ministry of Health,
Erzurum Provincial Directorate of Health Ethics
Committee, on April 17, 2009, and numbered 3/92. The
patients were interviewed and their diagnoses were
confirmed with the Structured Clinical Interview of DSM
Disorders (SCID). Following this, the Turkish version of
the Temperament Evaluation of Memphis, Pisa, Paris and
San Diego Autoquestionnaire (TEMPS-A) and the epilepsy
information form were applied.
The inclusion criteria were as follows: a diagnosis of
epilepsy for at least six months, agreement to participate in
the study, sufficient literacy to take the tests, and being in
the age range of 16-65 years. Exclusion criteria were as
follows: suffering from a cognitive disorder (e.g., mental
retardation or dementia) that might affect the accuracy of
test answers, suffering from an organic disorder (e.g., a
tumor in the frontal lobe) that might be directly associated
with epilepsy or the patient’s personality, and the use of
alcohol or drugs.
An information form prepared by the researchers was
used to gather sociodemographic information of patients
and the clinical features of epilepsy. After obtaining the
consent of the participants included in the study, the
epilepsy data form was completed, and the SCID-I was
carried out by a psychiatrist. Following the interview, the
participants were given the TEMPS-A tests, and the results
were evaluated.
Structured Clinical Interview for DSM-IV Axis I
Disorders (SCID-I) and Structured Clinical
Interview for DSM-IV Axis I Disorders, Clinical
Version (SCID-CV)
The SCID-I is a partially structured diagnostic
interview containing the DSM-IV diagnoses, translated to
Turkish and confirmed for validity/reliability by
Çorapçıoğlu et al. (1999). It starts with a sociodemographic
data guide and covers seven psychiatric diagnosis groups.
It is highly reliable for diagnosing serious psychiatric
disorders, and it is used as a standard interview in clinical
studies to confirm diagnoses (15,16).
Turkish Version of the Temperament Evaluation of
Memphis, Pisa, Paris, and San Diego
Autoquestionnaire (TEMPS-A)
The TEMPS-A, developed in 1997 by Akiskal et al., is
used to evaluate average scores for dominant affective
temperament and sub-types of affective temperament. The
validity/reliability of the Turkish version of the scale,
which consists of 99 items, was confirmed by Vahip et al.
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Affective temperaments in epilepsy
It is a Likert-type self-evaluation scale and comprises five
sub-dimensions assessing depressive, cyclothymic,
hyperthymic, irritable, and anxious temperaments (17).
Statistical Analyses
The statistical analysis was carried out using SPSS
13.0 for Windows. A chi-square (χ
2
) test was used for the
comparison of the epilepsy and control groups for the
evaluation of gender, profession, marital status, drug use
history, psychiatric diagnosis, and affective temperament
types.
In evaluating formal education, groups were established
for 8 years or less, 8-15 years, and 16 years or more. To
evaluate the relationship between education and affective
temperament, one-way ANOVA and post-hoc Scheffe tests
were applied.
A Student’s t-test was used for the comparison of
genders and groups for average age, disorder onset age,
frequency of seizures, and the TEMPS-A point averages of
the groups. Pearson correlation analysis was used to
evaluate the relationship between age and TEMPS-A point
averages.
A one-way ANOVA was used for the evaluation of the
relationship between frequency of seizures and
temperament characteristics of epilepsy patients, and a
post-hoc Scheffe test was used for an advanced analysis
between sub-groups. Multiple linear regression analysis
was used to determine whether epilepsy and its prognosis
were predictors of affective temperament characteristics
according to TEMPS-A scale scores.
In preparing the regression models, variables, factors
reported in the literature as influencing affective
temperaments, and statistical significances obtained in
previous steps were considered. Dummy variables were
created for parameters such as gender, presence of epilepsy,
and presence of MDD.
RESULTS
In total, 152 participants aged 16-65 years were
included in the study, 73 in the epilepsy group and 79 in
the control group. The average age of the epilepsy group
was 25.8±9.5, and the average age of the control group
was 27.7±8.2. The difference between the average ages
was not significant (p=0.19). There were 36 men and 37
women in the epilepsy group and 43 men and 36 women
in the control group. The chi-square test revealed no
significant difference between the two groups (p=0.53). In
terms of marital status, 48 participants in the epilepsy
group were single and 25 were married, while in the
control group, 52 were single and 27 were married. The
chi-square test revealed no significant difference between
the two groups (p=0.99). Regarding formal education, in
the epilepsy group, the number of individuals who had
received <8 years, 8-15 years, and >16 years of education
were 25, 35, and 13, respectively. In the control group,
these figures were 16, 36, and 27, respectively, indicating
that the individuals in the epilepsy group had a lower level
of education (p<0.05).
Evaluation of Affective Temperaments and
Related Factors
While 15 depressive, 5 cyclothymic, 11 irritable, and 8
anxious temperaments were detected in the epilepsy group,
only 4 depressive, 4 irritable, and 4 anxious temperaments
were detected in the control group. The higher results for
depressive temperament (p=0.004) and irritable
temperament (p=0.034) were statistically significant. No
hyperthymic temperaments were detected in either group.
An evaluation of the groups according to their average
TEMPS-A point averages revealed that the depressive
(p<0.001, t=-4.28), cyclothymic (p<0.001, t=-4.67),
irritable (p<0.001, t=-5.21), and anxious temperament
(p<0.001, t=-4.49) scores of the epilepsy group were
significantly higher than those of the control group.
However, there was no significant difference in
hyperthymic temperament scores (p=0.72, t=0.35) (Figure
1).
In all samples, a positive correlation was found between
age and depressive temperament scores (r=0.261, p=0.01).
Women had higher anxious and cyclothymic temperament
scores than men. The depressive temperament scores of
married persons were higher than those of singles
(married=8.25, single=6.63, t=-2.26, p=0.026).
Furthermore, the one-way ANOVA carried out for level of
education showed that those with lower levels of education
had higher depressive, cyclothymic, and irritable
temperament scores.
In the epilepsy group, cyclothymic temperament scores
in women (p=0.027, t=2.26) and single participants
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E. Yazici, A. B. Yazici, N. Aydin, A. O. Varoglu, I. Kirpinar
(p=0.037, t=2.12) were significantly higher (p<0.05).
MDD (p=0.035, χ
2
=4.455), and social phobia (p=0.002,
χ
2
=9.941) was significantly more frequent in epilepsy
patients. Furthermore, the number of individuals with a
psychiatric diagnosis was significantly higher in the
epilepsy group than in the control group (epilepsy: n=27,
control: n=9, p<0.001, χ
2
=13.750).
In both groups, presence of MDD was evident. In all
samples, depressive (p<0.001, t=-4.64), cyclothymic
(p=0.001 t=-3.53), irritable (p<0.001, t=-4.53), and
anxious (p<0.001, t=-6.24) temperament scores were
significantly higher in the group with the MDD diagnosis.
A regression model was prepared to determine
predictors of affective temperament scores in all samples.
Accordingly, the multiple linear regression model
(comprising independent variables such as the presence of
epilepsy, gender, marital status, level of education, and the
presence of MDD) was applied separately for each
affective temperament score (Table 1). This model
demonstrated that the presence of an epilepsy diagnosis
was an independent predictor of the differences between
the depressive, cyclothymic, irritable, and anxious
temperament scores. Gender was a predictor of depressive,
cyclothymic, and anxious temperament scores; level of
Figure 1: Comparison of the average TEMPS-A scores of the epilepsy and control groups
**: p<0.001
Tab le 1: Predictors obtained through multiple linear regression analysis of TEMPS-A scores
Epilepsy Gender Marital Status Education MDD R
2
Depressive
beta -0.244 -0.161 0.168 -0.164 0.262 0.255
P 0.001 0.049 0.032 0.030 0.001
Cyclothymic
beta -0.267 -0.192 -0.066 -0.207 -0.213 0.247
P 0.000 0.012 0.378 0.007 0.005
Hyperthymic
beta -0.011 -0.011 0.034 0.014 -0.215 0.045
P 0.899 0.894 0.688 0.865 0.011
Irritable
beta -0.335 0.052 -0.018 -0.047 0.288 0.240
P 0.000 0.496 0.811 0.532 0.000
Anxious
beta -0.236 -0.206 0.060 -0.159 0.380 0.333
P 0.001 0.004 0.393 0.026 0.000
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Affective temperaments in epilepsy
education was a predictor of depressive, cyclothymic, and
anxious temperament scores; and MDD was a predictor of
all temperament scores.
Relation of Depression with Affective
Temperaments in the Epilepsy Group
It was observed that those with MDD in the epilepsy
group had higher depressive (p=0.005, t=2.87), irritable
(p=0.019, t=-2.29), and anxious (p=0.001, t=-3.42)
temperament scores and lower hyperthymic (p=0.018,
t=2.41) temperament scores than those without (Figure 2).
Similarly, patients with both epilepsy and MDD had a
more frequent occurrence of depressive, cyclothymic, and
anxious temperaments (p<0.05).
Clinical Findings Regarding Epilepsy
The clinical characteristics of the epilepsy patients
regarding their epilepsy are given in Table 2. No significant
correlation was found between age at first seizure, duration
of illness, presence of auras, type of seizures, or affective
temperament characteristics.
A one-way ANOVA was applied to determine the
relationship between the frequency of seizures and
temperamental characteristics of epilepsy patients, and a
significant difference was detected in depressive
temperament among the TEMPS-A parameters. An
advanced analysis using the post-hoc Scheffe test showed
that the groups causing the significant difference in
depressive temperament were the group that had seizures
Tab le 2: Clinical Findings of Epilepsy Patients
Average age of first seizure (1- 63) 18.1 ± 10.6
Aura Yes n=35 47.9%
No n=38 52.1%
Frequency of Seizure <15 days n=16 21.9%
Once a month n=8 11%
Once every 3 months n=12 16.4%
Once every 6 months n=7 9.6%
Once a year or less n=28 38.2%
Average Duration Of Disease (years) (1-32) 7.72 ± 7.82
Seizure Type Partial seizure n=7 9.5%
Generalized Seizure n=66 90.5%
Figure 2: Comparison of the affective temperament scores of depressive and not depressive patients
*: p<0.05, MDD- : not depressive group, MDD+ : depressive group
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E. Yazici, A. B. Yazici, N. Aydin, A. O. Varoglu, I. Kirpinar
“more than once every 15 days” and the group that had
seizures “less than once a year” (p<0.05).
A multiple linear regression model wasformed with
clinical epilepsy characteristics (e.g., duration of illness,
type of seizures, frequency of seizures, and gender), MDD,
and marital status as independent variables. In this model,
duration of illness (β=0.226, p=0.036, R
2
=0.304), frequency
of seizures (β=0.375, p=0.001), and depression (β=0.226,
p=0.043) were predictors as independent variables. On the
other hand, only the presence of MDD (β=0.345, p=0.004,
R
2
=0.223) was a predictor of anxious temperament.
DISCUSSION
In this study, among the affective temperaments accepted
as the antecedents of MDs and important for determining
at-risk groups , the presence of depressive and irritable
temperaments and the depressive, cyclothymic, irritable, and
anxious temperament scores in the epilepsy group were found
to be significantly higher than those of the control group.
Recent studies show that affective temperament types
are subsyndromal indications and antecedents of MDs (12).
Irregularities in temperament are a familial genetic
characteristic for a tendency to manic-depressive episodes
(18). It has been stated that the probability of a dominant
affective temperament in persons with a history of affective
disorders in the family is two-fold (19). In a study
investigating the relation between affective temperaments
and MDD, it was disclosed that there was a strong correlation
between cyclothymic, depressive, and anxious temperaments
and inherited depression (19). Another study revealed that
high depressive temperament scores were related to
recurrent depressive disorder, and high hyperthymic and
cyclothymic temperament scores to bipolar disorders and
psychotic features that accompany bipolar disorder (20). In
our literature review, no study was found on the evaluation
of affective temperament in epilepsy patients. This study
has shown, for the first time, that epilepsy patients not only
tend to suffer from MDs, but also tend to have affective
temperaments that put them at risk for MDs.
Psychiatric Diagnosis Distribution in the
Epilepsy and Control Groups
The most frequently observed comorbidities in the
epilepsy group were depressive disorders led by MDD and
followed by anxiety disorders, which is supported by the
literature (21). Social phobia, not mentioned before in the
literature, was significantly more common in the epilepsy
group than in the control group. The distribution of other
diagnoses in the control group were in conformance with
literature (22).
This study has shown that in the epilepsy group, both
affective temperament diagnoses and depression were
more frequent than in the control group. In epilepsy
patients, especially in frontal lobe epilepsy patients, MDs
are observed frequently, the most common being
depression (21). Recent research has shown a decrease in
the volume of the hippocampus, a part of the limbic
system, in individuals suffering the depression that follows
epilepsy surgery, which begs the question of whether or
not there are common anatomical areas affected by both
epilepsy and depression (23). Understanding the
neurobiological causes underlying temperament will be a
key to understanding psychological disorders. One study
has shown that specific areas of the prefrontal cortex (the
dorsolateral prefrontal, anterior cingulate, and orbitofrontal
cortex) and the limbic system are associated with the three
main dimensions of temperament, namely, negative affect,
positive affect, and constraint (24). The diagnoses and
scores determined for epilepsy patients in this study may
be associated with the increased MD frequency in epilepsy
patients, suggesting a common neuroanatomical pathology,
particularly in the limbic system, besides a common
genetic tendency to MDs.
Association of Depression with TEMPS-A
Scores
In the epilepsy group, depressive, cyclothymic, and
anxious temperament numbers and scores were higher for
patients diagnosed with MDD comorbidity, and MDD was
a predictor of high depressive, irritable, and anxious
temperament scores, independent of epilepsy. This is in
line with the study of Lazary et al., which investigated the
association of affective temperaments with MD and
discussed the association of anxious, depressive, and
cyclothymic temperaments with high depression scores
(19). Through the current study, it can be said that the
findings are also valid for the epilepsy group. The study
carried out by Bostanci et al., showing the clinical findings
that become dissimilar when major depression accompanies
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Affective temperaments in epilepsy
epilepsy, also supports our findings (25). However, the
small number of cases in our study prevents the hypotheses
from being fully proven.
Association of Clinical Findings and
Personality Traits of Epilepsy Patients
In this study, the depressive temperament scores of
those having frequent seizures were higher than those who
had seizures once a year or less. Long illness duration and
frequent seizures in epilepsy are associated with higher
degrees of atrophy in white and gray matter (25).
It could be reasoned that individuals who have
frequent seizures have a harder time adapting to and
participating in social groups and feel rejected (26),
which may lead to higher depression scores. Moreover,
more frequent seizures may have caused a higher degree
of organic damage and a tendency to depressive
temperament due to social interaction in our participants.
As mentioned, depressive temperament may be a
predictor of depression.
In this study, the association of MD, epilepsy,
psychiatric comorbidity, and affective temperament in
epilepsy patients was investigated, and epilepsy patients
were found to have higher depressive, cyclothymic,
irritable, and anxious temperament scores. Furthermore,
anxious temperament in epilepsy patients was found to be
a predictor of MDD.
This study has formed a basis for the understanding of
affective temperament and associated factors in epilepsy.
Affective temperaments have increasing value in
identifying groups at risk for MDs, often encountered in
epilepsy as well, and in interpreting prognosis and etiology.
However, the small number of participants in our study
emerged as a limitation. Therefore, further studies using
larger samples may enable the determination of a common
etiology and thus the development of treatment and
perhaps even preventative approaches.
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    • "The temperament and character dimensions of the revised model are measured by Cloninger's Temperament Character Inventory (TCI) [21,22]. Cloninger's biopsychosocial model interprets personality in a multidimensional way; studies carried out using this model have asserted that personality characteristics are associated with positive and negative feelings, adaptive–maladaptive coping attitudes, and many clinical conditions such as depression, anxiety, and panic disorder [23]. In addition, detailed studies investigating the relationship between personality and burnout have been conducted [24,25]. "
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