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Validation of the brief TEMPS-M temperament questionnaire in a clinical Italian sample of bipolar and cyclothymic patients
Journal of Affective Disorders 260 (2020) 458–462
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Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research paper
Validation of the brief TEMPS-M temperament questionnaire in a clinical Italian sample of bipolar and cyclothymic patients
T
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Giovanna Ficoa, , Mario Lucianoa, Gaia Sampognaa, Francesca Zinnoa, Luca Steardo Jr.b, Giulio Perugic, Maurizio Pompilid, Alfonso Tortorellae, Umberto Volpef, Andrea Fiorilloa, Mario Maja a
Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy Psychiatry Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy c Department of Clinical and Experimental Medicine, Psychiatric Section, University of Pisa, Azienda Ospedaliera Universitaria Pisana (AOUP), Pisa, Italy d Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, S. Andrea Hospital, Sapienza University, Rome Italy e Department of Medicine, Division of Psychiatry, Clinical Psychology and Rehabilitation, University of Perugia, Perugia, Italy f Section of Psychiatry, Department of Neurosciences/DIMSC, School of Medicine, Università Politecnica delle Marche, Ancona, Italy b
A R T I C LE I N FO
A B S T R A C T
Keywords: TEMPS-M Affective temperaments Mood disorders Bipolar spectrum
Background: To assess psychometric proprieties of the short version of TEMPS-M in an Italian clinical sample of patients with bipolar disorder type I (BDI), type II (BDI) or cyclothymic disorder (CYC). Methods: All participants were recruited in two Italian university sites. They were asked to complete the Italian version of the short TEMPS-M, consisting of 35 items on a five-point Likert scale ranging from 1 to 5. The factorial structure of the instrument was assessed by principal components analysis with varimax rotation. The reliability of the subscales was assessed with Cronbach's alpha. Results: The 815 recruited patients had a diagnosis of BDI (430), CYC (227) or BDII (158); 60% of them were female and with a mean age of 44.4 ( ± 14.6) years. Cronbach's alpha coefficients of subscales ranged from 0.808 to 0.898. The factor analysis confirmed five dimensions (depressive, cyclothymic, hyperthymic, irritable, anxious), as in the English version of the scale. All temperaments were more represented in CYC than in BDI patients. Depressive and anxious temperaments were more represented in BDII than in BDI; the hyperthymic temperament was represented more in BDI than in BDII patients. Limitations: No other assessment instrument was used as a reference to assess the external or predictive validity of TEMPS-M; several socio-demographic and clinical characteristics have not been assessed. Conclusion: The Italian version of the short TEMPS-M shows good reliability and validity. It might be used in clinical and research settings, for the dimensional exploration of the investigated domains.
1. Introduction Bipolar disorder includes a gradient of severity, ranging from cyclothymic disorder to full-blown bipolar I disorder. A broader spectrum of bipolar psychopathology that is not captured by traditional categorical diagnoses has been defined involving the use of affective temperaments (Akiskal and Pinto, 1999). Temperament refers to a genetically determined emotional reactivity to the environment, which - in combination with life experiences - leads to the development of personality traits (Goldsmith et al., 1987). Based on the pioneering work of Kraepelin, who considered four basic affective “fundamental states” as subtypes of the manic-depressive
⁎
illness, namely depressive, manic, cyclothymic and irritable, Akiskal et al. (1983) conceptualized a spectrum of affective conditions extending from temperament to clinical episodes, and proposed criteria to define five temperaments: depressive, cyclothymic, hyperthymic, irritable and anxious. Cyclothymic temperament is characterized by a chronic cycling of mood polarities with unstable self-esteem and energy, irritable temperament by irritable and angry behaviors (Akiskal et al., 2005a), hyperthymic temperament by increased levels of energy and optimism (Akiskal and Akiskal, 1992), the anxious temperament by worrying attitudes, and depressive temperament is characterized by low levels of energy and introversion (Akiskal et al., 2005a). According to the Akiskal theory (Akiskal and Akiskal, 1992),
Corresponding author. E-mail address: giov.fi[email protected] (G. Fico).
https://doi.org/10.1016/j.jad.2019.09.034 Received 3 April 2019; Received in revised form 22 June 2019; Accepted 8 September 2019 Available online 09 September 2019 0165-0327/ © 2019 Elsevier B.V. All rights reserved.
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affective temperaments play a significant role in the clinical presentation and evolution of mood episodes and influence course of illness, symptoms’ severity and response to treatments (Rihmer et al., 2010). Moreover, the measurement of affective temperaments might be useful to identify patients at risk for suicide. In fact, several studies have found that cyclothymic, depressive and irritable temperaments are more frequently associated with a higher risk of suicidal behaviours, whereas hyperthymic temperament seems to be a protective factor (Pompili et al., 2008b). In order to assess affective temperaments, the Temperament Evaluation in Memphis, Pisa and San Diego (TEMPS) scale was originally developed in forms of interview (TEMPS-I) (Akiskal et al., 1998) or of self-administered questionnaire (TEMPS-A) (Akiskal et al., 2005b). The TEMPS-A, which consists of 110 items (Akiskal et al., 2005b) with “yes” or “no” answers, has been translated in several languages and has been widely used in a number of epidemiological and clinical studies involving psychiatric patients and healthy subjects (Bloink et al., 2005; Pompili et al., 2008a). However, its use in routine conditions has been scarce so far, mainly for length and time needed to completion (Elias et al., 2017). Akiskal et al. (2005a) validated a shorter 39-item version (Short TEMPS-A) for research and clinical purposes in patients with mood disorders, their relatives and in normal controls. This version has been validated in different languages in non-clinical samples as well in a sample of Italian students (Preti et al., 2015). Based on TEMPS-A, Erfurth et al. (2005) have developed the TEMPS-M, a shorter 35-item version, whose main change from the original version is the scoring of items. In fact, in this new TEMPS-M version the scoring is on a 1–5 Likert-type scale, rather than being a yes/no answer, thereby improving its clinical and research utility and allowing an exploration of the dimensionality of investigated domains. TEMPS-M has been validated in two independent non-clinical samples (Erfurth et al., 2005; Naderer et al., 2015). According to a recent review, all the different versions and dimensions of the TEMPS have adequate internal consistency reliabilities (Elias et al., 2017). Our study aims to assess psychometric proprieties of the short version of TEMPS-M in a clinical sample of patients with bipolar I, II or cyclothymic disorders.
Table 1 Socio-demographic and clinical characteristics of the sample (N = 815). Gender, male (N;%)
(317; 38,9)
Diagnosis: Bipolar disorder type I (N;%) Bipolar disorder type II (N;%) Cyclothymia (N;%) Age (mean ± SD)
(430; (158; (227; (44,4
52,8) 19,4) 27,9) ± 14,6)
analysis was performed on the subscales by entering the average of the items and using the principal component extraction method with Varimax rotation and Kaiser normalization. Differences in diagnosis and gender were tested using independent samples t-tests with Bonferroni correction. Pearson's correlation test was performed to analyze the correlation between age and affective temperaments. The Kaiser Meyer-Olkin (KMO) measure of sampling adequacy and Barlett's Test of Sphericity were reported for assessing factorability of the data. The level of significance was set at p < 0.001. All analyses were performed using the Statistical Package for Social Science software (SPSS), version 17.0. 3. Results A total of 815 patients filled in the questionnaire. 498 patients (61.1%) were females and 317 (38.9%) were males. The average age of the sample was 44.4 ( ± 14.6) years. Patients had a diagnosis of bipolar I disorder (52.8%, n = 430), cyclothymia (27.9%, n = 227) and bipolar II disorder (19.4%, n = 158) (Table 1). On the 1–10 appropriateness scale, the mean scores ranged between 6 and 7 for 71% of the items and were above 7 for 25% of the items; only one item (n. 28) scored slightly below 6. Five subscales emerged from the Cronbach's alpha analysis: depressive (alpha value = 0.851), cyclothymic (alpha value = 0.898), hyperthymic (alpha value = 0.832), irritable (alpha value = 0.874) and anxious (alpha value = 0.808); each subscale consists of seven items. KMO measure of sampling adequacy for the sample was 0.914, corresponding to the recommended value of at least 0.6; Bartlett's Test of Sphericity was statistically significant (p < 0.0001), supporting the factorability of the correlation matrix. The confirmatory factor analysis identified five dimensions (depressive, cyclothymic, hyperthymic, irritable and anxious) that were confirmed by the Varimax rotation (with Kaiser normalization). For each of the five factors defined by seven items in consecutive order, the factor loadings were larger than 0.50. Cross-loadings on other factors did not exceed 0.30. The intercorrelations of the subscales are shown in Table 2. All temperaments were positively correlated among them; only the hyperthymic temperament was negatively correlated with the depressive, cyclothymic and anxious subscales. Mean scores and rates of dominant affective temperament according to gender are reported in Table 3. Depressive, cyclothymic and anxious temperaments are more frequent in women, while irritable in men; no differences were found between males and females as regards the hyperthymic temperament. Pearson's test showed a negative correlation between depressive, cyclothymic, anxious and irritable temperament and age, no correlation between age and hyperthymic
2. Methods The Italian version of the TEMPS-M was developed by translating the original scale in Italian, back-translating it into English and adjusting the Italian final version as needed. The short version of the TEMPS-M consists of 35 items on a five-point Likert scale ranging from 1 to 5 (1 = “not at all”; 2 = “a little”; 3 = “moderately”; 4 = “much”; 5 “very much”). The items assess five different temperaments: depressive, cyclotomic, hyperthymic, irritable and anxious. Patients were recruited at the Department of Psychiatry of the University of Campania “Luigi Vanvitelli” and at the Psychiatric Unit of the University of Pisa between February and May 2018. Inclusion criteria were the following: 1) age above 18 years; 2) diagnosis of bipolar I disorder (BDI), bipolar II disorder (BDII) or cyclothymia (CYC) according to the DSM-5. Exclusion criteria were: 1) severe physical or mental comorbidities requiring an urgent treatment; 2) current manic, depressive or mixed episode; 3) severe cognitive, motor, or visual impairment. Informed consent for participation in the study was obtained for all recruited patients. The study has been approved by the relevant ethical review board.
Table 2 Intercorrelations of subscales.
2.1. Statistical analysis The face validity of the items was explored by means and standard deviations of the ratings on the 1–10 appropriateness scale. Pearson's rho coefficient was used to evaluate the variance of the responses. The single items were grouped into the hypothesized subscales by the Cronbach's alpha analysis (content validity). In order to identify the main areas covered by the tool (construct validity), confirmatory factor
Depressive Cyclothymic Hyperthymic Irritable ⁎ ⁎⁎
459
Anxious
Depressive
,518⁎⁎ ,436⁎⁎ -,085* ,248⁎⁎
,512⁎⁎ -,212⁎⁎ ,323⁎⁎
p < 0,05 (2-tails). p < 0,01 (2-tails).
Cyclothymic
Irritable
,512⁎⁎
,323⁎⁎ ,359⁎⁎ ,152⁎⁎
-,062 ,359⁎⁎
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Table 3 Dominant affective temperament according to gender.
Depressive Cyclothymic Hyperthymic Irritable Anxious ⁎
Total (n = 815) Mean S.D.
Male (n = 317) Mean SD
Female (n = 498) Mean SD
Dominant affective temperament, males vs females p
19,4439 19,4667 18,7877 14,9680 16,9422
18,7089 18,7816 19,3185 15,6877 15,3344
19,9131 19,9032 18,4516 14,5071 17,9698
0,013* 0,039* – 0,011* 0,0001*
677,306 754,960 625,592 642,889 672,931
642,594 756,179 613,328 657,481 660,422
695,143 751,690 631,542 629,725 661,259
p < 0,05.
4. Discussion
Table 4 Correlation between age and affective temperaments. Subscales
Pearson correlation coefficient
Depressive Cyclothymic Hyperthymic Irritable Anxious
-,164⁎⁎ -,175⁎⁎ -,012 -,169⁎⁎ -,072*
⁎ ⁎⁎
The study confirmed the five-factor structure of the original scale, including cyclothymic, depressive, irritable, hyperthymic and anxious subscales. Our findings are consistent with previous studies conducted in Italy, in which the TEMPS-A with 110 items and the short version of the TEMPS-A were used in non-clinical adults (Pompili et al., 2008a). As expected, the short version of the TEMPS-M requires less time to be completed, and therefore it may be used more easily in clinical and research settings. As a research instrument, indeed, its ease and swiftness of administration make it appropriate for studies with large samples as well as for screening procedures. It has been reported that the phenotypes represented by the TEMPS-A can be associated with several genes involved in the risk of developing mood disorders or psychoses (Greenwood et al., 2013). Moreover, these phenotypes may also significantly influence quality of life, adherence and response to pharmacological treatments (de Aguiar Ferreira et al., 2014), illness severity and global functioning (Pompili et al., 2013). Therefore, the shortened version of the TEMPS-M may be useful in order to: a) identify behavioral traits as possible markers and predictors of progression; b)
p < 0,05 (2 tailed). p < 0,01 (2 tailed).
temperament emerged (Table 4). All temperaments were more represented in cyclothymic than in bipolar I patients; depressive, cyclothymic and irritable temperaments were more represented in cyclothymic than in bipolar II patients, depressive and anxious temperaments were more represented in bipolar II than in bipolar I patients; only the hyperthymic temperament was represented in bipolar I more than in bipolar II patients (Fig. 1).
Fig. 1. Differences in affective temperaments according to diagnosis. BDI, bipolar disorder type I; BDII, bipolar disorder type II; CYC, cyclothymia. a: means difference between BDI and BDII; b: means difference between BDII and CYC; c: means difference between BDI and CYC. a, b, c: p < 0,005 (critical P-value after Bonferroni correction). 460
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proprieties of TEMPS-M in non-clinical samples have already been evaluated, to our knowledge no study has tested the short version of the TEMPS-M in a large clinical sample, as we did in this study. Moreover, we have recruited a heterogeneous sample of patients with BD-I, BD-II and cyclothymia, usually misrepresented in other studies. In fact, this is one of the first studies exploring affective temperaments in a sample of cyclothymic patients. In addition, the brief TEMPS-M has a dimensional rating, while the TEMPS-A and TEMPS-I adopted a categorical approach; it is likely that the dimensional approach will contribute to a more accurate representation of patients’ attitudes. The following limitations must be acknowledged: 1) most patients’ socio-demographic and clinical characteristics, such as number and type of episodes, years of illness, predominant polarity, suicide attempts, and their level of education and occupational status have not been collected; 2) participants were recruited only in two centres, and therefore our findings cannot be considered fully generalizable to the Italian context; 3) no other assessment instrument was used as reference to assess external or predictive validity of TEMPS-M. In conclusion, the Italian 35-item TEMPS-M has shown good psychometric properties in terms of reliability and validity and it is characterized by a dimensional structure, supporting the concept of the bipolar spectrum. Results of our paper can have major implications for clinical practice. In fact, the assessment of affective temperaments in routine settings could provide clinicians with more information about the clinical characterization of mood disorders, such as suicidality, aggressive behavior, social functioning and treatments response (Aguiar Ferreira et al., 2013). Moreover, affective temperaments can be considered as mediators of the clinical outcome of bipolar disorders and predictors of interepisodic symptoms. Therefore, the short version of TEMPS-M, with its dimensional approach, can be useful to assess affective temperaments for research and clinical purposes. Further studies on different diagnostic samples should be done in order to better understand the predisposing and pathoplastic significance of affective temperament and to plan a patient-oriented long-term management.
highlight inter-episodic manifestations of affective disorders and c) plan an individualized long-term treatment (Elias et al., 2017). The assessment of affective temperaments is a topic of interest as a potential predictor of suicidal behaviors. In fact, it has been reported that cyclothymic, depressive, or irritable temperament types, particularly with a diagnosed mood disorder, may be at risk to present suicidal behavior, while hyperthymic temperament has proven to be a protective factor (Vazquez et al., 2018). Although temperaments are considered to be relatively stable throughout life (von Zerssen and Akiskal, 1998), the effect of gender and age on temperament is controversial. In fact, a six-year follow-up study by Kawamura et al. (2010) showed that affective temperaments are stable over time, independently from type, gender and age; on the contrary, other studies found gender differences for cyclothymic, depressive, anxious and hyperthymic temperaments (Rihmer et al., 2010; Placidi et al., 1998; Vazquez et al., 2012), but not for the irritable one (Erfurth et al., 2005). In our study, a gender effect was found with the depressive, cyclothymic and anxious temperaments being more frequent in females (Erfurth et al., 2005; Akiskal et al., 2005a; Bloink et al., 2005). As shown in other studies (Buss and Plomin, 1975), also in our sample affective temperaments tend to remain stable over time with the exception of hyperthymic, which is softener in elderly people. Of course, this finding is speculative given the cross-sectional nature of the study and further longitudinal studies are needed (Placidi et al., 1998; Nigg, 2006). The intercorrelations between subscales were in line with the theoretical formulations on affective temperaments. However depressive, cyclothymic and anxious temperaments resulted strongly related each other and inversely related with hyperthymic temperament. This observation is consistent with previous reports with different versions of the TEMPS in Italian (Perugi et al., 2012), German (Brieger et al., 2003) and Hungarian (Gonda et al., 2009) bipolar disorder clinical samples, selected in different phases of the illness, as well as in Lebanese general population (Karam et al., 2007). In other words, the affective temperamental dispositions measured by TEMPS-M can be also measured as the expression of two second level dimensions, the first mainly characterized by mood-emotional instability (depressive-cyclothymicanxious disposition) and the second by mood-emotional intensity (hyperthymic disposition). As in previous studies, the hyperthymic temperament negatively correlated with the depressive-cyclothymic-anxious subscales, confirming that hyperthymic temperament may differ significantly from the others in terms of prognosis, severity and suicidality rates (Pompili et al., 2008b). Temperamental irritability may be related with variant of both depressive-cyclothymic-anxious and hyperthymic temperamental subtypes. In our sample, patients with cyclothymia showed higher scores in all five temperaments in comparison with BDI patients, and higher scores in depressive, cyclothymic and irritable subscales in comparison with BDII patients. This can be related to the conceptualization of cyclothymia as a disorder in continuity with a temperamental disposition characterized by emotional dysregulation, mood instability and impulsivity that lays between non-pathological mood swings and fullblown mood disorders (Perugi et al., 2015), serving as a potential vulnerability marker (Akiskal and Pinto, 1999). In this perspective, a more consistent relationship with temperamental dimensions than bipolar I and II disorders can be easily explained. We also found that the hyperthymic temperament is more represented in BDI than in BDII patients, while anxious and depressive temperaments are more represented in BDII than in BDI patients. These findings are in line with the observation that patients with BDII spend most of their time in the depressive phase (Angst et al., 2002) and depressive and anxious temperaments may be more related to a prevalently depressive course of the illness. On the contrary, the hyperthymic disposition may be associated with prevalently (hypo) manic course, more common in bipolar I patients (Perugi et al., 2018). This study presents several strengths. Although the psychometric
Role of funding source This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. CRediT authorship contribution statement Giovanna Fico: Writing - original draft, Investigation. Mario Luciano: Writing - original draft. Gaia Sampogna: Methodology, Validation, Software, Supervision. Francesca Zinno: Investigation, Methodology, Validation, Software, Supervision. Luca Steardo: Investigation, Methodology, Validation, Software, Supervision. Giulio Perugi: Methodology, Project administration, Supervision, Writing review & editing. Maurizio Pompili: Methodology, Project administration, Supervision, Writing - review & editing. Alfonso Tortorella: . Umberto Volpe: Methodology, Validation, Software, Supervision. Andrea Fiorillo: Methodology, Project administration, Supervision, Writing - review & editing. Mario Maj: Methodology, Project administration, Supervision, Writing - review & editing. Declaration of Competing Interest All authors declare that they have no conflicts of interest. Acknowledgment None. Supplementary materials Supplementary material associated with this article can be found, in 461
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References Akiskal, H.S., Akiskal, K., 1992. Cyclothymic, hyperthymic, and depressive temperaments as subaffective variants of mood disorders. American Psychiatric Press Review of Psychiatry 11, 43–62. Akiskal, H.S., Akiskal, K.K., Haykal, R.F., Manning, J.S., Connor, P.D., 2005a. TEMPS-A: progress towards validation of a self-rated clinical version of the temperament evaluation of the Memphis, Pisa, Paris, and San Diego autoquestionnaire. J. Affect. Disord. 85, 3–16. https://doi.org/10.1016/j.jad.2004.12.001. Akiskal, H.S., Hirschfeld, R.M., Yerevanian, B.I., 1983. The relationship of personality to affective disorders. Arch. Gen. Psychiatry 40, 801–810. Akiskal, H.S., Mendlowicz, M.V., Jean-Louis, G., Rapaport, M.H., Kelsoe, J.R., Gillin, J.C., Smith, T.L., 2005b. TEMPS-A: validation of a short version of a self-rated instrument designed to measure variations in temperament. J. Affect. Disord. 85, 45–52. https:// doi.org/10.1016/j.jad.2003.10.012. Akiskal, H.S., Pinto, O., 1999. The evolving bipolar spectrum. prototypes I, II, III, and IV. Psychiatr. Clin. North Am. 22, 517–534 vii. Akiskal, H.S., Placidi, G.F., Maremmani, I., Signoretta, S., Liguori, A., Gervasi, R., Mallya, G., Puzantian, V.R., 1998. TEMPS-I: delineating the most discriminant traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population. J. Affect. Disord. 51, 7–19. Angst, J., Gamma, A., Lewinsohn, P., 2002. The evolving epidemiology of bipolar disorder. World Psychiatry 1, 146–148. Bloink, R., Brieger, P., Akiskal, H.S., Marneros, A., 2005. Factorial structure and internal consistency of the German TEMPS-A scale: validation against the NEO-FFI questionnaire. J. Affect. Disord. 85, 77–83. https://doi.org/10.1016/S0165-0327(03) 00101-0. Brieger, P., Roettig, S., Ehrt, U., Wenzel, A., Bloink, R., Marneros, A., 2003. TEMPS-A scale in “mixed” and “pure” manic episodes: new data and methodological considerations on the relevance of joint anxious-depressive temperament traits. J. Affect. Disord. 73, 99–104. Buss, A.H., Plomin, R., 1975. A temperament theory of personality development. A Temperament Theory of Personality Development. Wiley-Interscience, Oxford, England. de Aguiar Ferreira, A., Vasconcelos, A.G., Neves, F.S., Correa, H., 2014. Affective temperaments and antidepressant response in the clinical management of mood disorders. J. Affect. Disord. 155, 138–141. https://doi.org/10.1016/j.jad.2013.10.038. Elias, L.R., Kohler, C.A., Stubbs, B., Maciel, B.R., Cavalcante, L.M., Vale, A.M.O., Gonda, X., Quevedo, J., Hyphantis, T.N., Soares, J.C., Vieta, E., Carvalho, A.F., 2017. Measuring affective temperaments: a systematic review of validation studies of the temperament evaluation in memphis pisa and san diego (TEMPS) instruments. J. Affect. Disord. 212, 25–37. https://doi.org/10.1016/j.jad.2017.01.023. Erfurth, A., Gerlach, A.L., Hellweg, I., Boenigk, I., Michael, N., Akiskal, H.S., 2005. Studies on a German (Munster) version of the temperament auto-questionnaire TEMPS-A: construction and validation of the briefTEMPS-M. J. Affect. Disord. 85, 53–69. https://doi.org/10.1016/S0165-0327(03)00102-2. Ferreira, Aguiar, de, A., Vasconcelos, A.G., Neves, F.S., Laks, J., Correa, H., 2013. Affective temperaments: familiality and clinical use in mood disorders. J. Affect. Disord. 148, 53–56. https://doi.org/10.1016/j.jad.2012.11.047. Goldsmith, H.H., Buss, A.H., Plomin, R., Rothbart, M.K., Thomas, A., Chess, S., Hinde, R.A., McCall, R.B., 1987. Roundtable: what is temperament? Four approaches. Child Dev 58, 505–529. Gonda, X., Fountoulakis, K.N., Rihmer, Z., Lazary, J., Laszik, A., Akiskal, K.K., Akiskal, H.S., Bagdy, G., 2009. Towards a genetically validated new affective temperament scale: a delineation of the temperament phenotype of 5-HTTLPR using the TEMPS-A. J. Affect. Disord. 112, 19–29. https://doi.org/10.1016/j.jad.2008.03.012. Greenwood, T.A., Badner, J.A., Byerley, W., Keck, P.E., McElroy, S.L., Remick, R.A., Sadovnick, A.D., Akiskal, H.S., Kelsoe, J.R., 2013. Heritability and genome-wide SNP linkage analysis of temperament in bipolar disorder. J. Affect. Disord. 150,
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Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research paper
Validation of the brief TEMPS-M temperament questionnaire in a clinical Italian sample of bipolar and cyclothymic patients
T
⁎
Giovanna Ficoa, , Mario Lucianoa, Gaia Sampognaa, Francesca Zinnoa, Luca Steardo Jr.b, Giulio Perugic, Maurizio Pompilid, Alfonso Tortorellae, Umberto Volpef, Andrea Fiorilloa, Mario Maja a
Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy Psychiatry Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy c Department of Clinical and Experimental Medicine, Psychiatric Section, University of Pisa, Azienda Ospedaliera Universitaria Pisana (AOUP), Pisa, Italy d Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, S. Andrea Hospital, Sapienza University, Rome Italy e Department of Medicine, Division of Psychiatry, Clinical Psychology and Rehabilitation, University of Perugia, Perugia, Italy f Section of Psychiatry, Department of Neurosciences/DIMSC, School of Medicine, Università Politecnica delle Marche, Ancona, Italy b
A R T I C LE I N FO
A B S T R A C T
Keywords: TEMPS-M Affective temperaments Mood disorders Bipolar spectrum
Background: To assess psychometric proprieties of the short version of TEMPS-M in an Italian clinical sample of patients with bipolar disorder type I (BDI), type II (BDI) or cyclothymic disorder (CYC). Methods: All participants were recruited in two Italian university sites. They were asked to complete the Italian version of the short TEMPS-M, consisting of 35 items on a five-point Likert scale ranging from 1 to 5. The factorial structure of the instrument was assessed by principal components analysis with varimax rotation. The reliability of the subscales was assessed with Cronbach's alpha. Results: The 815 recruited patients had a diagnosis of BDI (430), CYC (227) or BDII (158); 60% of them were female and with a mean age of 44.4 ( ± 14.6) years. Cronbach's alpha coefficients of subscales ranged from 0.808 to 0.898. The factor analysis confirmed five dimensions (depressive, cyclothymic, hyperthymic, irritable, anxious), as in the English version of the scale. All temperaments were more represented in CYC than in BDI patients. Depressive and anxious temperaments were more represented in BDII than in BDI; the hyperthymic temperament was represented more in BDI than in BDII patients. Limitations: No other assessment instrument was used as a reference to assess the external or predictive validity of TEMPS-M; several socio-demographic and clinical characteristics have not been assessed. Conclusion: The Italian version of the short TEMPS-M shows good reliability and validity. It might be used in clinical and research settings, for the dimensional exploration of the investigated domains.
1. Introduction Bipolar disorder includes a gradient of severity, ranging from cyclothymic disorder to full-blown bipolar I disorder. A broader spectrum of bipolar psychopathology that is not captured by traditional categorical diagnoses has been defined involving the use of affective temperaments (Akiskal and Pinto, 1999). Temperament refers to a genetically determined emotional reactivity to the environment, which - in combination with life experiences - leads to the development of personality traits (Goldsmith et al., 1987). Based on the pioneering work of Kraepelin, who considered four basic affective “fundamental states” as subtypes of the manic-depressive
⁎
illness, namely depressive, manic, cyclothymic and irritable, Akiskal et al. (1983) conceptualized a spectrum of affective conditions extending from temperament to clinical episodes, and proposed criteria to define five temperaments: depressive, cyclothymic, hyperthymic, irritable and anxious. Cyclothymic temperament is characterized by a chronic cycling of mood polarities with unstable self-esteem and energy, irritable temperament by irritable and angry behaviors (Akiskal et al., 2005a), hyperthymic temperament by increased levels of energy and optimism (Akiskal and Akiskal, 1992), the anxious temperament by worrying attitudes, and depressive temperament is characterized by low levels of energy and introversion (Akiskal et al., 2005a). According to the Akiskal theory (Akiskal and Akiskal, 1992),
Corresponding author. E-mail address: giov.fi[email protected] (G. Fico).
https://doi.org/10.1016/j.jad.2019.09.034 Received 3 April 2019; Received in revised form 22 June 2019; Accepted 8 September 2019 Available online 09 September 2019 0165-0327/ © 2019 Elsevier B.V. All rights reserved.
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affective temperaments play a significant role in the clinical presentation and evolution of mood episodes and influence course of illness, symptoms’ severity and response to treatments (Rihmer et al., 2010). Moreover, the measurement of affective temperaments might be useful to identify patients at risk for suicide. In fact, several studies have found that cyclothymic, depressive and irritable temperaments are more frequently associated with a higher risk of suicidal behaviours, whereas hyperthymic temperament seems to be a protective factor (Pompili et al., 2008b). In order to assess affective temperaments, the Temperament Evaluation in Memphis, Pisa and San Diego (TEMPS) scale was originally developed in forms of interview (TEMPS-I) (Akiskal et al., 1998) or of self-administered questionnaire (TEMPS-A) (Akiskal et al., 2005b). The TEMPS-A, which consists of 110 items (Akiskal et al., 2005b) with “yes” or “no” answers, has been translated in several languages and has been widely used in a number of epidemiological and clinical studies involving psychiatric patients and healthy subjects (Bloink et al., 2005; Pompili et al., 2008a). However, its use in routine conditions has been scarce so far, mainly for length and time needed to completion (Elias et al., 2017). Akiskal et al. (2005a) validated a shorter 39-item version (Short TEMPS-A) for research and clinical purposes in patients with mood disorders, their relatives and in normal controls. This version has been validated in different languages in non-clinical samples as well in a sample of Italian students (Preti et al., 2015). Based on TEMPS-A, Erfurth et al. (2005) have developed the TEMPS-M, a shorter 35-item version, whose main change from the original version is the scoring of items. In fact, in this new TEMPS-M version the scoring is on a 1–5 Likert-type scale, rather than being a yes/no answer, thereby improving its clinical and research utility and allowing an exploration of the dimensionality of investigated domains. TEMPS-M has been validated in two independent non-clinical samples (Erfurth et al., 2005; Naderer et al., 2015). According to a recent review, all the different versions and dimensions of the TEMPS have adequate internal consistency reliabilities (Elias et al., 2017). Our study aims to assess psychometric proprieties of the short version of TEMPS-M in a clinical sample of patients with bipolar I, II or cyclothymic disorders.
Table 1 Socio-demographic and clinical characteristics of the sample (N = 815). Gender, male (N;%)
(317; 38,9)
Diagnosis: Bipolar disorder type I (N;%) Bipolar disorder type II (N;%) Cyclothymia (N;%) Age (mean ± SD)
(430; (158; (227; (44,4
52,8) 19,4) 27,9) ± 14,6)
analysis was performed on the subscales by entering the average of the items and using the principal component extraction method with Varimax rotation and Kaiser normalization. Differences in diagnosis and gender were tested using independent samples t-tests with Bonferroni correction. Pearson's correlation test was performed to analyze the correlation between age and affective temperaments. The Kaiser Meyer-Olkin (KMO) measure of sampling adequacy and Barlett's Test of Sphericity were reported for assessing factorability of the data. The level of significance was set at p < 0.001. All analyses were performed using the Statistical Package for Social Science software (SPSS), version 17.0. 3. Results A total of 815 patients filled in the questionnaire. 498 patients (61.1%) were females and 317 (38.9%) were males. The average age of the sample was 44.4 ( ± 14.6) years. Patients had a diagnosis of bipolar I disorder (52.8%, n = 430), cyclothymia (27.9%, n = 227) and bipolar II disorder (19.4%, n = 158) (Table 1). On the 1–10 appropriateness scale, the mean scores ranged between 6 and 7 for 71% of the items and were above 7 for 25% of the items; only one item (n. 28) scored slightly below 6. Five subscales emerged from the Cronbach's alpha analysis: depressive (alpha value = 0.851), cyclothymic (alpha value = 0.898), hyperthymic (alpha value = 0.832), irritable (alpha value = 0.874) and anxious (alpha value = 0.808); each subscale consists of seven items. KMO measure of sampling adequacy for the sample was 0.914, corresponding to the recommended value of at least 0.6; Bartlett's Test of Sphericity was statistically significant (p < 0.0001), supporting the factorability of the correlation matrix. The confirmatory factor analysis identified five dimensions (depressive, cyclothymic, hyperthymic, irritable and anxious) that were confirmed by the Varimax rotation (with Kaiser normalization). For each of the five factors defined by seven items in consecutive order, the factor loadings were larger than 0.50. Cross-loadings on other factors did not exceed 0.30. The intercorrelations of the subscales are shown in Table 2. All temperaments were positively correlated among them; only the hyperthymic temperament was negatively correlated with the depressive, cyclothymic and anxious subscales. Mean scores and rates of dominant affective temperament according to gender are reported in Table 3. Depressive, cyclothymic and anxious temperaments are more frequent in women, while irritable in men; no differences were found between males and females as regards the hyperthymic temperament. Pearson's test showed a negative correlation between depressive, cyclothymic, anxious and irritable temperament and age, no correlation between age and hyperthymic
2. Methods The Italian version of the TEMPS-M was developed by translating the original scale in Italian, back-translating it into English and adjusting the Italian final version as needed. The short version of the TEMPS-M consists of 35 items on a five-point Likert scale ranging from 1 to 5 (1 = “not at all”; 2 = “a little”; 3 = “moderately”; 4 = “much”; 5 “very much”). The items assess five different temperaments: depressive, cyclotomic, hyperthymic, irritable and anxious. Patients were recruited at the Department of Psychiatry of the University of Campania “Luigi Vanvitelli” and at the Psychiatric Unit of the University of Pisa between February and May 2018. Inclusion criteria were the following: 1) age above 18 years; 2) diagnosis of bipolar I disorder (BDI), bipolar II disorder (BDII) or cyclothymia (CYC) according to the DSM-5. Exclusion criteria were: 1) severe physical or mental comorbidities requiring an urgent treatment; 2) current manic, depressive or mixed episode; 3) severe cognitive, motor, or visual impairment. Informed consent for participation in the study was obtained for all recruited patients. The study has been approved by the relevant ethical review board.
Table 2 Intercorrelations of subscales.
2.1. Statistical analysis The face validity of the items was explored by means and standard deviations of the ratings on the 1–10 appropriateness scale. Pearson's rho coefficient was used to evaluate the variance of the responses. The single items were grouped into the hypothesized subscales by the Cronbach's alpha analysis (content validity). In order to identify the main areas covered by the tool (construct validity), confirmatory factor
Depressive Cyclothymic Hyperthymic Irritable ⁎ ⁎⁎
459
Anxious
Depressive
,518⁎⁎ ,436⁎⁎ -,085* ,248⁎⁎
,512⁎⁎ -,212⁎⁎ ,323⁎⁎
p < 0,05 (2-tails). p < 0,01 (2-tails).
Cyclothymic
Irritable
,512⁎⁎
,323⁎⁎ ,359⁎⁎ ,152⁎⁎
-,062 ,359⁎⁎
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Table 3 Dominant affective temperament according to gender.
Depressive Cyclothymic Hyperthymic Irritable Anxious ⁎
Total (n = 815) Mean S.D.
Male (n = 317) Mean SD
Female (n = 498) Mean SD
Dominant affective temperament, males vs females p
19,4439 19,4667 18,7877 14,9680 16,9422
18,7089 18,7816 19,3185 15,6877 15,3344
19,9131 19,9032 18,4516 14,5071 17,9698
0,013* 0,039* – 0,011* 0,0001*
677,306 754,960 625,592 642,889 672,931
642,594 756,179 613,328 657,481 660,422
695,143 751,690 631,542 629,725 661,259
p < 0,05.
4. Discussion
Table 4 Correlation between age and affective temperaments. Subscales
Pearson correlation coefficient
Depressive Cyclothymic Hyperthymic Irritable Anxious
-,164⁎⁎ -,175⁎⁎ -,012 -,169⁎⁎ -,072*
⁎ ⁎⁎
The study confirmed the five-factor structure of the original scale, including cyclothymic, depressive, irritable, hyperthymic and anxious subscales. Our findings are consistent with previous studies conducted in Italy, in which the TEMPS-A with 110 items and the short version of the TEMPS-A were used in non-clinical adults (Pompili et al., 2008a). As expected, the short version of the TEMPS-M requires less time to be completed, and therefore it may be used more easily in clinical and research settings. As a research instrument, indeed, its ease and swiftness of administration make it appropriate for studies with large samples as well as for screening procedures. It has been reported that the phenotypes represented by the TEMPS-A can be associated with several genes involved in the risk of developing mood disorders or psychoses (Greenwood et al., 2013). Moreover, these phenotypes may also significantly influence quality of life, adherence and response to pharmacological treatments (de Aguiar Ferreira et al., 2014), illness severity and global functioning (Pompili et al., 2013). Therefore, the shortened version of the TEMPS-M may be useful in order to: a) identify behavioral traits as possible markers and predictors of progression; b)
p < 0,05 (2 tailed). p < 0,01 (2 tailed).
temperament emerged (Table 4). All temperaments were more represented in cyclothymic than in bipolar I patients; depressive, cyclothymic and irritable temperaments were more represented in cyclothymic than in bipolar II patients, depressive and anxious temperaments were more represented in bipolar II than in bipolar I patients; only the hyperthymic temperament was represented in bipolar I more than in bipolar II patients (Fig. 1).
Fig. 1. Differences in affective temperaments according to diagnosis. BDI, bipolar disorder type I; BDII, bipolar disorder type II; CYC, cyclothymia. a: means difference between BDI and BDII; b: means difference between BDII and CYC; c: means difference between BDI and CYC. a, b, c: p < 0,005 (critical P-value after Bonferroni correction). 460
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proprieties of TEMPS-M in non-clinical samples have already been evaluated, to our knowledge no study has tested the short version of the TEMPS-M in a large clinical sample, as we did in this study. Moreover, we have recruited a heterogeneous sample of patients with BD-I, BD-II and cyclothymia, usually misrepresented in other studies. In fact, this is one of the first studies exploring affective temperaments in a sample of cyclothymic patients. In addition, the brief TEMPS-M has a dimensional rating, while the TEMPS-A and TEMPS-I adopted a categorical approach; it is likely that the dimensional approach will contribute to a more accurate representation of patients’ attitudes. The following limitations must be acknowledged: 1) most patients’ socio-demographic and clinical characteristics, such as number and type of episodes, years of illness, predominant polarity, suicide attempts, and their level of education and occupational status have not been collected; 2) participants were recruited only in two centres, and therefore our findings cannot be considered fully generalizable to the Italian context; 3) no other assessment instrument was used as reference to assess external or predictive validity of TEMPS-M. In conclusion, the Italian 35-item TEMPS-M has shown good psychometric properties in terms of reliability and validity and it is characterized by a dimensional structure, supporting the concept of the bipolar spectrum. Results of our paper can have major implications for clinical practice. In fact, the assessment of affective temperaments in routine settings could provide clinicians with more information about the clinical characterization of mood disorders, such as suicidality, aggressive behavior, social functioning and treatments response (Aguiar Ferreira et al., 2013). Moreover, affective temperaments can be considered as mediators of the clinical outcome of bipolar disorders and predictors of interepisodic symptoms. Therefore, the short version of TEMPS-M, with its dimensional approach, can be useful to assess affective temperaments for research and clinical purposes. Further studies on different diagnostic samples should be done in order to better understand the predisposing and pathoplastic significance of affective temperament and to plan a patient-oriented long-term management.
highlight inter-episodic manifestations of affective disorders and c) plan an individualized long-term treatment (Elias et al., 2017). The assessment of affective temperaments is a topic of interest as a potential predictor of suicidal behaviors. In fact, it has been reported that cyclothymic, depressive, or irritable temperament types, particularly with a diagnosed mood disorder, may be at risk to present suicidal behavior, while hyperthymic temperament has proven to be a protective factor (Vazquez et al., 2018). Although temperaments are considered to be relatively stable throughout life (von Zerssen and Akiskal, 1998), the effect of gender and age on temperament is controversial. In fact, a six-year follow-up study by Kawamura et al. (2010) showed that affective temperaments are stable over time, independently from type, gender and age; on the contrary, other studies found gender differences for cyclothymic, depressive, anxious and hyperthymic temperaments (Rihmer et al., 2010; Placidi et al., 1998; Vazquez et al., 2012), but not for the irritable one (Erfurth et al., 2005). In our study, a gender effect was found with the depressive, cyclothymic and anxious temperaments being more frequent in females (Erfurth et al., 2005; Akiskal et al., 2005a; Bloink et al., 2005). As shown in other studies (Buss and Plomin, 1975), also in our sample affective temperaments tend to remain stable over time with the exception of hyperthymic, which is softener in elderly people. Of course, this finding is speculative given the cross-sectional nature of the study and further longitudinal studies are needed (Placidi et al., 1998; Nigg, 2006). The intercorrelations between subscales were in line with the theoretical formulations on affective temperaments. However depressive, cyclothymic and anxious temperaments resulted strongly related each other and inversely related with hyperthymic temperament. This observation is consistent with previous reports with different versions of the TEMPS in Italian (Perugi et al., 2012), German (Brieger et al., 2003) and Hungarian (Gonda et al., 2009) bipolar disorder clinical samples, selected in different phases of the illness, as well as in Lebanese general population (Karam et al., 2007). In other words, the affective temperamental dispositions measured by TEMPS-M can be also measured as the expression of two second level dimensions, the first mainly characterized by mood-emotional instability (depressive-cyclothymicanxious disposition) and the second by mood-emotional intensity (hyperthymic disposition). As in previous studies, the hyperthymic temperament negatively correlated with the depressive-cyclothymic-anxious subscales, confirming that hyperthymic temperament may differ significantly from the others in terms of prognosis, severity and suicidality rates (Pompili et al., 2008b). Temperamental irritability may be related with variant of both depressive-cyclothymic-anxious and hyperthymic temperamental subtypes. In our sample, patients with cyclothymia showed higher scores in all five temperaments in comparison with BDI patients, and higher scores in depressive, cyclothymic and irritable subscales in comparison with BDII patients. This can be related to the conceptualization of cyclothymia as a disorder in continuity with a temperamental disposition characterized by emotional dysregulation, mood instability and impulsivity that lays between non-pathological mood swings and fullblown mood disorders (Perugi et al., 2015), serving as a potential vulnerability marker (Akiskal and Pinto, 1999). In this perspective, a more consistent relationship with temperamental dimensions than bipolar I and II disorders can be easily explained. We also found that the hyperthymic temperament is more represented in BDI than in BDII patients, while anxious and depressive temperaments are more represented in BDII than in BDI patients. These findings are in line with the observation that patients with BDII spend most of their time in the depressive phase (Angst et al., 2002) and depressive and anxious temperaments may be more related to a prevalently depressive course of the illness. On the contrary, the hyperthymic disposition may be associated with prevalently (hypo) manic course, more common in bipolar I patients (Perugi et al., 2018). This study presents several strengths. Although the psychometric
Role of funding source This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. CRediT authorship contribution statement Giovanna Fico: Writing - original draft, Investigation. Mario Luciano: Writing - original draft. Gaia Sampogna: Methodology, Validation, Software, Supervision. Francesca Zinno: Investigation, Methodology, Validation, Software, Supervision. Luca Steardo: Investigation, Methodology, Validation, Software, Supervision. Giulio Perugi: Methodology, Project administration, Supervision, Writing review & editing. Maurizio Pompili: Methodology, Project administration, Supervision, Writing - review & editing. Alfonso Tortorella: . Umberto Volpe: Methodology, Validation, Software, Supervision. Andrea Fiorillo: Methodology, Project administration, Supervision, Writing - review & editing. Mario Maj: Methodology, Project administration, Supervision, Writing - review & editing. Declaration of Competing Interest All authors declare that they have no conflicts of interest. Acknowledgment None. Supplementary materials Supplementary material associated with this article can be found, in 461
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the online version, at doi:10.1016/j.jad.2019.09.034.
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