Bipolar sensation seeking is associated with a propensity to abuse rather than to temperamental characteristics

Eur Psychiatry 2001 ; 16 : 289-92 © 2001 Éditions scientifiques et médicales Elsevier SAS. All rights reserved S0924933801005806/FLA

ORIGINAL ARTICLE

Bipolar sensation seeking is associated with a propensity to abuse rather than to temperamental characteristics C. Henry1,2*, F. Bellivier3, F. Sorbara1, S. Tangwongchai3, J. Lacoste1, M. Faure-Chaigneau3, M. Leboyer3 1

Service Universitaire de Psychiatrie, CHS Charles Perrens, 121 rue de la Béchade, F-33076 Bordeaux cedex, France; 2 INSERM-U 394 ‘Neurobiologie intégrative’, rue Camillle Saint Saëns, 33077 Bordeaux cedex, France; 3 Service Universitaire de Psychiatrie Adulte, Hôpital Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, F-94010 Créteil cedex, France; 4 INSERM U-513 ‘Neurobiologie et Psychiatrie’, Faculté de Médecine de Créteil, 8 rue du Général Sarrail, 94010 Créteil cedex, France (Received 15 October 2000; revised 25 April 2001; accepted 8 June 2001)

Summary – Objective. As some temperament profiles may be markers of genetic vulnerability traits, we aimed to compare sensation seeking in euthymic bipolar patients and in controls. Methods. One hundred ninety-four patients fulfilling DSM-IV diagnostic criteria for bipolar disorders (BP), 81% of whom presented type I BP, and 95 controls were included in this study. Euthymia was assessed using both the MADRS and Bech mania scales. Subjects were evaluated using the French abbreviated form of Zuckerman’s Sensation Seeking Scale (SSS), which provide a total score (TS) and four subscores: Thrill and Adventure Seeking (TAS), Experience Seeking (ES), Disinhibition (Dis), and Boredom Susceptibility (BS). Results. SSS total score differed significantly between men (17.2 ± 0.5) and women (15.3 ± 0.6) (P = 0.02) and all the subscores were negatively correlated with age. On adjustement for sex and age, we found that bipolar patients had a high Dis score (P = 0.003). However, if the same analysis was performed with a lifetime history of alcohol abuse or dependence as a covariable, no such difference was found (P = 0.436). The SSS demonstrated a high degree of test-retest reliability (ICC = 0.91). Conclusion. These results suggest that sensation seeking assessed with the SSS is not a temperament characteristic associated with bipolar disorders but is instead linked to a tendency towards alcohol abuse. © 2001 Éditions scientifiques et médicales Elsevier SAS bipolar disorder / sensation seeking / substance use disorders

INTRODUCTION If bipolar patients in remission are compared with normal controls, no significant differences are found for most personality variables [11]. However, some traits may predispose individuals to development of mood disorders. Sensation seeking is a trait involving the need

*Correspondence and reprints. E-mail address: [email protected] (C. Henry).

for varied, novel and complex sensations and experiences. When exposed to repetitive stimuli, the sensation seeker is thought to become nonreponsive and to experience boredom sooner than other individuals. Few studies have been devoted to the relationship between bipolar disorders and sensation seeking. Zuckerman and Neeb [23] have suggested that sensation seeking

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may vary during affective episodes. Indeed, hypomanic and manic behavior could be viewed as exaggerations of strong sensation seeking behavior [24]. Zuckerman and Neeb [23] reported a study carried out in the general population. They reported that SSS scores appeared to be unrelated to psychiatric diagnosis, but were high in individuals reporting a history of manic-depressive or sociopathic spectrum disorder (including alcoholism and drug abuse). Nevertheless, according to Eysenck [9], the psychopathological trait most frequently related to sensation seeking is hypomania. Depressed subjects, even when they return to euthymia, score significantly lower than controls on the sensation seeking scale [5]. The aim of this study was to compare euthymic bipolar patients to control subjects using the Sensation Seeking Scale [22] to evaluate whether certain traits could be used to distinguish between these two groups. As sensation seeking may vary with mood, we retested individuals within a 6–12-month period, to check that sensation seeking was stable in bipolar patients as it is in control subjects [22]. METHODS Subjects Patients with bipolar type I (BP-I) (who had suffered at least one manic episode) or type II (BP-II) (with a history of at least one major depressive episode and one hypomanic access) disorders were recruited from consecutive admissions to the psychiatric inpatient department of Pitié-Salpêtrière Hospital in Paris and Charles Perrens Hospital in Bordeaux. All patients provided informed written consent for participation. Patients were interviewed by trained psychiatrists with a French version of the Diagnosis Interview for Genetic Studies (DIGS) [15], providing DSM-IV Axis-I diagnoses. Personality traits were assessed when patients were euthymic and as confirmed with the MADRS [14] and Bech and Rafaelsen Mania Rating Scale [1]. The controls were blood donors recruited at PitiéSalpêtrière Hospital, Paris. They were also interviewed using the DIGS and all subjects with a personal or family history of mood disorders or suicide attempt were excluded. To minimize the morbidity of subjects in the control group, only blood donors older than 35 years were included. Within 6 to 12 months of the first evaluation, re-test was performed in outpatients only if the MADRS score

was less than 12 and the Bech and Rafaelsen Mania Rating Scale less than 6. Sensation seeking scale The French abbreviated form of the Sensation Seeking Scale (SSS, [22]; translated into French by Carton et al. [4]) was used to explore the sensation seeking trait. The SSS (Form V) is a forced-choice questionnaire consisting of four ten-item subscales: Thrill and Adventure Seeking (TAS), Experience Seeking (ES), Disinhibition (Dis), and Boredom Susceptibility (BS). A total score (TS) is calculated based on all 40 items. The TAS subscale measures the desire to engage in physically risky activities or sports. The ES items measure the need for a broad variety of inner experiences achieved through travel, drugs, music, art, and an unconventional lifestyle. They also include some element of resistance to authority and conformity. The Dis subscale concerns the seeking of excitement through social and sexual activity, parties and drinking. The BS subscale measures intolerance of sameness, monotony, and restlessness when not stimulated. Statistical analysis The analyses were performed using SPSS version 9.0 computer software. A one-way analysis of variance was used to study the relationship between temperament characteristics concerning sensation seeking and diagnosis (BP versus control) with age and sex as covariables. As an association between sensation-seeking characteristics and substance use disorders has been reported, we also included lifetime history of alcohol misuse as a covariable. We analysed the test-retest reliability of SSS in bipolar patients. RESULTS Sample characteristics The sample of patients (N = 194) consisted of 81% BP I (N = 157) and 19% BP II (N = 37) subjects. The mean age at interview was 43 ± 13.9 years for BP I and 49 ± 14.3 years for BP II. The proportion of women was higher for BP II patients (65%) (N = 24) than for BP I patients (58%) (N = 91). The proportions of men and women also differed between bipolar patients and controls, with 59% (N = 56) of men for control subjects and 41% (N = 79) men for bipolar patients. Eur Psychiatry 2001 ; 16 : 289–92

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Patients were clinically euthymic on inclusion, as confirmed by mean MADRS scores (2.43 ± 2.87; range 0–13) and mean Bech and Rafaelsen Mania Rating Scale scores (2.93 ± 1.79 ; range 0–5). Effect of sex and age on SSS scores For the whole population of bipolar and control subjects, total SSS scores differed significantly different between men and women (F(1,1) = 5.9, df = 289, P = 0.025). The total score and all of the subscores were negatively correlated with age (TS: r = –0.40; Dis: r = –0.26; TAS: r = –0.42; ES: r = –0.27; BS: r = –0.21). Thus, as age and sex significantly affected SSS scores, these two factors were included as covariables in our analysis. SSS in bipolar and control subjects An analysis of variance, adjusted for sex and age, showed no significant difference in total SSS score between bipolar patients and controls (F(1,3) = 1.5, df = 286, P = 0.221). There was a significant difference between bipolar patients and controls only for the Dis subscore (F(1,3) = 8.84, df = 286, P = 0.003), for which patients with BP disorder had significantly higher scores than control subjects (table I). However, these results are due to alcohol abuse or dependence because, if we included alcohol abuse or dependence as a covariable, this effect was not significant (F(1,4) = 0.7, df = 218, P = 0.403). Stability of SSS scores in bipolar patients Fifty-five bipolar patients were retested with SSS within 6 to 12 months of the first evaluation. The SSS was highly reliable because the ICC was 0.91 for total score, and for the subscales was between 0.90 for TAS and 0.78 for BS.

DISCUSSION The comparison of SSS scores for 194 BP patients and 95 controls showed that the BP group had higher scores for the disinhibition subscale than did the controls. However, this difference may be attributed to a history of alcohol abuse or dependence in BP patients. The personality traits assessed by the SSS were stable in BP patients throughout the euthymic period. Consistent with previous studies, we found that SSS scores were higher in men than in women and declined with age [2, 3, 12, 19, 20, 22]. Several lines of evidence suggest that these sex and age differences may stem from differences in androgen levels, which seem to play a role in sensation seeking [8]. These sex and age differences led us to perform a covariate analysis to adjust for these confounding factors. Bipolar disorders were not responsible for the higher disinhibition scores in bipolar patients, as this high score accounted for comorbidity for alcohol abuse and dependence. A few previous studies have reported an association between substance abuse disorders and sensation seeking. Liraud and Verdoux [13] showed that a lifetime history of alcohol misuse was associated with higher scores for the ‘experience seeking’ and ‘disinhibition’ subscales of the SSS, independently of diagnosis. Studies on college students have shown that consumers of various substances score higher than nonconsumers for all subscales of the SSS [10, 16, 21]. To our knowledge, this is the first study to compare sensation seeking scores on the SSS between BP patients and control subjects. Our results seem to indicate that sensation seeking does not differentiate bipolar patients from control subjects. This trait appears to be more linked to substance use disorders. However, some items of the SSS directly explore drug or alcohol use, or the desire to use drugs. We cannot rule out the possibility that the association between substance use and high scores for the Dis subscale is not strengthened, at least

Table I. Means and standard deviation of the subscales and of the total score for the SSS in the various groups. All bipolar

Zuckerman General (TS) Disinhibition (Dis) Adventure (TAS) Experience Seeking (ES) Boredom Susceptibility (BS) Eur Psychiatry 2001 ; 16 : 289–92

N = 194

Bipolar without alcohol misuse N = 97

Bipolar with alcohol misuse N = 29

Control N = 95

16.49 (± 7.75) 3.45 (± 2.47) 4.82 (± 3.09) 5.37 (± 2.49) 2.87 (± 2)

15.67 (± 7.77) 2.93 (± 2.21) 4.87 (± 3.23) 5.18 (± 2.55) 2.70 (± 2.08)

22.07 (± 5.98) 5.83 (± 2.09) 5.76 (± 3.02) 6.21 (± 1.72) 4.28 (± 1.89)

15.68 (± 6.06) 2.68 (±1.86) 5.36 (± 2.65) 5.24 (± 2.26) 2.40 (± 1.92)

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in part, by the presence of these items [13]. One limitation of this study is the lack of non-bipolar patients with alcohol misuse. The inclusion of such patients would have made it possible to explore the effect of the interaction between the two diagnoses on the SSS. The constitution of the control group might also raise criticism since blood donors may have particular temperamental profiles. However, our control group appears similar to control groups in other studies [22, 23]. Moreover, it is not easy to compare data from different studies because of the impact of age and sex on the SSS scores. In a previous study [17], we reported that euthymic bipolar patients assessed with the Tridimensional Personality Questionnaire (TPQ) of Cloninger [6, 7] present a higher Harm Avoidance and Reward Dependence score than controls. These results take into account age, sex, educational level and alcoholic and substance use disorder as covariables. The study by Young et al. [18] has also assessed fully recovered bipolar patients using the TPQ. They have shown that novelty seeking scores were elevated in bipolar subjects compared with unipolar depression and non-patient subjects, but they did not take into account in their analysis the co-morbidity with substance abuse. However, the TPQ seems to be better suited than the SSS for studies of trait markers in bipolar patients, even when there is a co-morbidity with substance abuse. ACKNOWLEDGEMENTS This work was supported by a grant from the Programme Hospitalier de Recherche Clinique (PHRC 2001). REFERENCES 1 Bech P, Rafaelsen OJ, Kramp P, Bolwig TG. The mania rating scale: scale construction and inter-observer agreement. Neuropharmacology 1978 ; 1 : 430-1. 2 Blackburn R. Sensation seeking, impulsivity, and psychopathic personality. J Consult Clin Psychol 1969 ; 33 : 571-4. 3 Brownfield CA. Optimal stimulation levels of normal and disturbed subjects in sensory deprivation. Psychologia 1966 ; 9 : 27-38. 4 Carton S, Jouvent R, Widlöcher D. Cross-cultural validity of the Sensation Seeking Scale: development of a French abbreviated form. Eur Psychiatry 1992 ; 7 : 225-34.

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