Cloninger's temperament and character dimensions of personality in patients with major depressive disorder

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Comprehensive Psychiatry 50 (2009) 556 – 561 www.elsevier.com/locate/comppsych

Cloninger's temperament and character dimensions of personality in patients with major depressive disorder Feryal Cam Celikela,⁎, Samet Koseb , Birgul Elbozan Cumurcua , Unal Erkorkmazc , Kemal Sayard , Jeffrey J. Borckardtb , C. Robert Cloningere b

a Department of Psychiatry, Gaziosmanpasa University School of Medicine, 60100 Tokat, Turkey Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA c Department of Biostatistics, Gaziosmanpasa University School of Medicine, 60100 Tokat, Turkey d Department of Psychiatry, Bakirkoy Mental Hospital, Istanbul 43147, Turkey e Department of Psychiatry, Washington University School of Medicine, St Louis, MO 63110, USA

Abstract In this present study, we examined the relationship between the Cloninger's dimensional psychobiologic model of personality and depression in an outpatient population with major depressive disorder. Eighty-one depressed outpatients (67 women, 14 men) and 51 healthy controls (35 women, 16 men) filled out the Turkish version of the Temperament and Character Inventory (TCI). Depression severity was evaluated by using the 17-item Hamilton Depression Rating Scale and the 21-item Beck Depression Inventory. Depressed patients exhibited statistically significant higher scores for harm avoidance and lower scores for self-directedness compared to healthy controls. Sentimentality (RD1) and dependence (RD4) subscale scores of reward dependence and spiritual acceptance (ST3) subscale of self-transcendence were significantly higher; attachment (RD3) subscale of reward dependence, responsibility (SD1), purposefulness (SD2), resourcefulness (SD3), and congruent second nature (SD5) subscales of self-directedness were significantly lower in the depressed group. In the depressed patient group, main effects of sex were significant for reward dependence and cooperativeness; the scores of both dimensions were higher for women. The Beck Inventory was positively correlated with harm avoidance and negatively correlated with novelty seeking and selfdirectedness dimensions (P b .05). The duration of depression (16.33 ± 20.18 months) or the mean onset age of depression (28.68 ± 8.11 years) did not show significant correlations with TCI scales. This study confirms the relationship between harm avoidance and depression and suggests a relationship between self-directedness and depression. © 2009 Elsevier Inc. All rights reserved.

1. Introduction There exists a complex relationship between personality and depression. Personality features may predispose an individual to depression; the personality can be modified after the onset of depressive episode; and the personality can modify the clinical presentation of a depressive episode, and also, depressive personality can be considered as a subtype of a depressive disorder [1-3]. In Cloninger's psychobiologic model of temperament and character, relationships between the structure and development of personality and psychiatric disorders are described [4,5]. This model postulates that personality is comprehen⁎ Corresponding author. Tel.: +90 356 212 95 00x1288; fax: +90 356 213 31 79. E-mail address: [email protected] (F.C. Celikel). 0010-440X/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2008.11.012

sively developed with respect to genetic traits, learning, and insight into the self-concept. Cloninger's model consists of 4 temperament and 3 character dimensions, all of which are viewed as being the results of continuous interactions during the life span [6]. Temperament is largely genetically determined, independently manifested in early life, and configures automatic behavior responses. Four dimensions of temperament are novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence (P). Novelty seeking refers to a heritable bias in the activation and initiation of behavior. Harm avoidance indicates a heritable bias for inhibition and cessation of behaviors. Reward dependence refers to a heritable bias for maintenance of ongoing behavior. Persistence refers to eagerness of effort in response to signals of anticipated reward vs laziness, ambitious overachieving in response to intermittent frustrative nonreward vs underachieving [7].

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Character involves individual differences in higher cognitive processes. Character regulates the cognitive processes of sensory perception and emotion provoked by temperament, leading to the development of a mature concept of the self in the personal, social, and spiritual arenas. These traits are determined more by environment rather than heredity. Self-directedness (SD) refers to identification with the autonomous self and the confidence to deal with any situation in accordance with one's goals and values. Cooperativeness (C) indicates the extent to which individuals view other people as a part of the self. Selftranscendence (ST) refers to identification with a unity of all things in the world [4]. There exists a complex relationship between personality and depression. Personality features may predispose an individual to depression; the personality can be modified after a depression; the personality can modify the clinical presentation of a depressive disorder; and finally the personality can be considered such as a subclinical manifestation of a depressive disorder [1,2]. Previous reports suggest that different personality traits interact with each other and that the effects are independently related to depression [6]. Joffe et al [8] demonstrated higher scores on HA in patients with major depression before and after successful treatment with antidepressants. Harm avoidance is positively correlated with mood, anxiety, and anxious personality disorders [9-13]. Chien and Dunner [14] investigated the state vs trait issue and found increased HA scores in depressed patients that moved toward values of normal controls after successful treatment. Consistently, higher HA and lower SD are found to be correlated with depression [6,15-17]. In a recent study with a universityderived sample population, lower SD independently predicted specific depression [6]. In this study, we examined the putative relationship between personality dimensions and depressive symptom first time in a group of Turkish outpatients referred for treatment of major depressive disorder and healthy controls. 2. Material and methods 2.1. Participants This study was conducted in outpatients with major depressive disorder who were admitted to the Psychiatric Unit of the Gaziosmanpasa University School of Medicine (Tokat, Turkey). The sample was composed of 81 outpatients (67 women, 14 men) with a mean age of 30.54 years (SD + 7.7 years) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria [18-20] for major depressive disorder, either a single episode or recurrent, and unaccompanied by psychotic features. The control group was composed of 51 healthy controls (35 women, 16 men), with a mean age of 32.75 years (SD + 8.7) years. The healthy controls were volunteering individuals with no psychiatric history or current psychiatric complaints. They have been

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recruited among the staff from Gaziosmanpasa University Hospital and their families. They all underwent an interview to rule out psychiatric disorders. Patients and controls had no history of mania or hypomania and were free of any medical illness and any history of neurologic disease. After complete description of the study, all the subjects gave written informed consent before participation and the study was carried out according to the basic principles for all medical research of the Declaration of Helsinki-fifth revision. 2.2. Measures Depression severity was evaluated with a clinician-rated scale, namely the 17-item Hamilton Depression Rating Scale [21,22], and with a self-report scale, specifically the 21-item Beck Depression Inventory [23,24]. The mean scores of the Hamilton and Beck scales in the depressed and the control groups were 19.57 ± 3.38 vs 4.73 ± 2.16 and 27.43 ± 7.06 vs 8.84 ± 5.37, respectively. The depressed patients completed a Turkish version of the 240-item self-questionnaire (Turkish-TCI) at the end of the pyschiatric interview, and the control group received the instruction to complete the questionnaire at home. All participants gave informed consent. The TCI is a 240-item self-administered questionnaire that measures the 4 temperament dimensions (NS, HA, RD, and P) and the 3-character dimensions (SD, C, and ST) [4]. The Turkish-TCI has been validated by Kose et al [25] in a Turkish sample of 683 healthy volunteers. All diagnostic assessments and clinical ratings were performed by 2 staff psychiatrists (FCC and BEC). 2.3. Statistical analysis The variables in the present study were examined with the Kolmogorov-Smirnov test of normality. All variables were normally distributed. An independent sample t test was used for comparisons between the patient and the control groups. Within-group correlations between TCI scores were performed using the Pearson correlation coefficient. Multiple stepwise linear regression was performed with the depression scores of the 2 scales taken as dependent variables. All statistical analyses were performed using SPSS for Windows, version 13.0 (SPSS, Chicago, Ill). 3. Results The mean scores for each of the 7 personality scales and their subscales are presented in Table 1 for both depressed patients and healthy controls. Depressed patients exhibited statistically significant higher scores for HA with all its subscales. Although RD did not differ between the 2 groups, the subscales RD1 and RD4 were significantly higher, whereas RD3 was significantly lower in the depressed patients. For SD, all subscale scores, except SD4, were significantly lower in the depressed patients compared to controls. In contrast, the 2 groups did not differ for NS, C,

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Table 1 Comparison of personality dimensions between depressed patients and healthy controls Depressed (n = 81)

NS NS1 (exploratory excitability) NS2 (impulsiveness) NS3 (extravagance) NS4 (disorderliness) HA HA1 (anticipatory worry) HA2 (fear of uncertainty) HA3 (shyness with strangers) HA4 (fatigability and asthenia) RD RD1 (sentimentality) RD3 (attachment) RD4 (dependence) P SD SD1 (responsibility) SD2 (purposefulness) SD3 (resourcefulness) SD4 (self-acceptance) SD5 (congruent second nature) C C1 (social acceptance) C2 (empathy) C3 (helpfulness) C4 (compassion) C5 (integrated conscience) ST ST1 (self-forgetfulness) ST2 (transpersonal identity) ST3 (spiritual acceptance)

Controls (n = 66)

M

SD

M

SD

t

P

17.07 5.68 3.88 4.04 3.48 24.56 8.51 5.38 4.40 6.27 15.65 7.95 4.42 3.28 5.42 23.54 3.33 4.46 2.48 5.62 7.65 29.15 5.49 4.10 4.79 7.16 7.60 18.64 5.90 4.80 7.94

4.64 1.99 2.08 2.22 1.53 5.50 2.04 1.37 2.22 2.35 2.95 1.69 1.76 1.42 2.00 7.39 2.22 2.16 1.48 2.40 2.04 5.31 1.66 1.32 1.42 2.72 1.01 5.04 2.45 2.15 2.37

17.80 6.11 3.71 4.39 3.59 17.37 6.02 4.53 2.94 3.88 14.69 7.20 5.02 2.47 5.37 28.78 5.00 5.61 3.64 6.08 8.45 28.92 5.69 4.10 4.92 6.84 7.37 17.69 5.71 5.16 6.82

5.25 1.54 1.85 2.32 1.76 7.68 2.72 2.03 2.04 2.70 2.57 1.70 1.38 1.36 1.81 7.29 2.35 2.13 1.34 2.68 2.08 5.49 1.64 1.30 1.64 2.43 1.10 5.63 2.49 2.17 2.81

−0.836 −1.335 0.479 −0.881 −0.369 5.807 5.601 2.645 3.773 5.370 1.928 2.496 −2.183 3.261 0.137 −3.989 −4.101 −2.997 −4.560 −1.028 −2.169 −0.236 −0.651 0.003 −0.488 0.679 1.247 1.014 0.443 −0.920 2.444

.405 .184 .633 .380 .713 b.001 b.001 .010 b.001 b.001 .056 .014 .031 .001 .891 b.001 b.001 .003 b.001 .306 .032 .814 .516 .998 .626 .498 .215 .313 .659 .359 .016

and ST, except for its subscale, ST3, which was significantly high in depressed patients. In the depressed patient group, main effects of sex were significant for RD and C; the scores of both dimensions were

higher for women. Concerning the subscales, RD3, RD4, C2, and C3 were higher in women, whereas RD1, C1, C4, and C5 did not reach a significance level between men and women. Concerning the SD dimension, no difference was found between the sexes, except SD5, which was significantly higher in women. In the control group, main effects of sex were significant only for the SD dimension and its SD1 subscale, the scores were higher in men. The duration of depression (16.33 ± 20.18 months) or the mean onset age of depression (28.68 ± 8.11 years) did not show significant correlations with TCI scales. The correlations between TCI dimensions and the age were not significant in both groups. In depressed patients with a positive family history, RD scores were significantly lower, compared to patients with no history of depression in the family. The correlations among the 4 dimensions of temperament and the 3 dimensions of character in depressed and healthy groups are summarized in Table 2. Within the depressed group, the significant correlations related HA with SD and ST, RD with C, P with SD and C, and SD with C and ST. Within the control group, the significant correlations related HA with RD and SD, NS with P and SD, and ST with SD. As shown in Table 3, among the group of depressed outpatients, the Hamilton scale scores were positively and significantly correlated with HA, but not with NS, RD, P, SD, C, and ST dimensions. Again, among the group of depressed outpatients, the Beck Inventory scores were positively correlated with HA and negatively correlated with NS and SD but not with RD, P, C, and ST dimensions. Table 4 displays the results of the stepwise linear regression models with depression as the dependent variable. The HA scale was a strong predictor of depression, measured with both scales. Depression was also related to NS with the Beck scale but not with the

Table 2 Correlations between temperament and character scales and age within the depressed and the control groups Scale Depressed group

Control group

NS HA RD P SD C ST Age NS HA RD P SD C ST Age

NS

HA

−0.005 0.033 −0.191 −0.207 −0.088 0.026 −0.200

0.145 −0.156 −0.618 −0.184 0.364 −0.019

0.201 0.021 0.403 0.052 0.091

0.233 0.415 0.124 −0.033

−0.234 0.049 −0.552 −0.384 −0.069 0.241 0.182

0.293 −0.196 −0.409 0.016 0.112 0.092

−0.095 −0.168 0.242 0.117 −0.089

0.252 0.128 −0.136 −0.031

Coefficients of 0.30 or higher are shown in bold.

RD

P

SD

C

ST

0.383 0.469 0.047

−0.149 0.052

−0.022

0.152 −0.417 0.058

−0.010 −0.167

0.045

Age

F.C. Celikel et al. / Comprehensive Psychiatry 50 (2009) 556–561 Table 3 Correlation coefficients of TCI dimensions with Hamilton Depression Rating Scale scores and Beck Depression Inventory scores NS Hamilton Depression Rating Scale Beck Depression Inventory

HA

RD

P

SD

C

ST

r −0.092 0.272 0.138 0.012 −0.093 0.076 0.119 P .414 .014 .219 .913 .408 .500 .289 r −0.221 0.259 0.092 0.040 −0.241 0.034 0.209 P .047 .019 .414 .722 .030 .764 .062

Hamilton scale. Other TCI scales were not significantly related to depression.

4. Discussion The principal findings of the present study are that depressed patients exhibit higher HA and lower SD scores compared to healthy controls. These results are consistent with a number of previous reports linking high HA [3,10,16,26,27] and low SD [3,6,27,28] with depression. However, the relationship between personality and depression seems more complex. Personality features may not only predispose an individual to the onset of depression but may also affect the expression of depression or a separate process is responsible for both personality factors and depression [29]. Harm avoidance, defined as a tendency to respond intensely to signals of aversive stimuli, thereby learning to avoid punishment and novelty appears to be a measure that is elevated during depressive states [14,30]. Moreover, Mulder

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and Joyce [30] (1994) have reported a significant difference between HA scores assessed initially and after 6 weeks of antidepressant treatment. In the present study, we confirm a significant association between this dimension and the severity of depression as assessed by the Hamilton Depression Rating Scale and Beck Depression Inventory. Thus, HA is state-dependent in depression. It is also possible that the experience of depressive episodes negatively affect selfconcept such that the reporting of HA traits is more likely [27]. Another consistent finding from previous studies of personality dimensions in depressive disorders is that low SD (defined as the ability of an individual to adapt, regulate, and control behavior to fit situations in accord with his chosen goals and values) is associated with depression. This finding, also supported in our study, supports the idea that immaturity of self-concept is a vulnerability factor for negative affectivity in general [6]. The SD construct includes cognitive functions such as self-esteem, internal locus of control, problem-solving, coping behaviors, and perceived support resources. As with HA, SD scores are also influenced by depressed mood at the time of assessment [3,26,31]. Future studies should address this issue by measuring personality dimensions prospectively in a long-term cohort as they progress through episodes of depression and recovery. In the present study, levels of HA, NS, and SD appear to be related with the severity of depressive symptom. The correlation between HA and SD is in accordance with several previous studies [3,16,28,32]. The finding that the NS dimension was correlated with depression severity (using the Beck Depression Inventory) is of interest because in many studies, NS was not reported to be affected by the clinical

Table 4 Multiple stepwise regression of depression (models summary) Groups

Variables

Model coefficients β

Hamilton Depression Rating Scale

Standard error of β

Models summary 2

P

R

F

P

9.254 2.508

b.001 .014

0.074

6.291

.014

−0.835 0.921 0.509 0.876 1.187 0.202

.406 .360 .612 .384 .239 .840

5.657 −2.067 2.426

b.001 .042 .018

0.116

5.106

.008

0.586 0.370 −1.594 0.593 1.217

.560 .712 .115 .555 .227

t

Included variables Constant HA NS RD P SD C ST

15.474 .167

1.672 0.066 Excluded variables

−.091 .101 .056 .121 .130 .024

Beck Depression Inventory

Included variables Constant NS HA RD P SD C ST

25.004 −.334 .331 .063 .041 −.222 .065 .139

4.420 0.162 0.137 Excluded variables

Depression (Hamilton Depression Rating Scale scores and Beck Depression Inventory scores) is a dependent variable.

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state of depressed patients [14,17,32]. This finding might reflect the differences in self-report and clinical rating methods for measuring the severity of depression. Our findings showed that RD was lower in depressive patients with a history of depression in the family. Reward dependence is described as a tendency to intensively respond to signals of reward to be rewarded. Subjects with lower scores on RD are described as less sentimental and less socially attached; they generally are less dependent on the approval of others. This result could be a consequence of the influence of depressed parents upon this particular temperament component. Sex differences concerning the temperament and the character dimensions have been assessed in several studies [3,32,33]. These studies have reported that men tend to have higher NS scores and lower HA and C scores as well as RD scores than women. In our study, for the depressed group, the results showed a main sex effect for RD and C, both dimensions significantly higher for women, and for the control group, main effects of sex only for the SD dimension, significantly higher in men. Several studies have demonstrated that some dimensions, and more particularly the NS dimension, varied with age [33,34]. Moreover, SD and C are reported to have a strong correlation with age [4]. However; we do not report a relation between age and the TCI dimensions. The negative results could be explained by the lower mean age in our sample. In the present study, the NS subscale exploratory excitability (NS1) is lower among the depressive group as compared to the controls. This result is different from the studies, which have reported that NS was not affected by clinical state of depressed patients [14,17,32,34]. The lower score observed in the present study concerning the NS1 subscale could correspond to the difficulty for depressed patients to initiate novel behavior and to actively explore the environment. This might have resulted from the chronicity of depression that is more than a year from the first episode in this particular sample. Finally, the present study confirms that the TCI scales are related among themselves. The relationships observed are consistent with those reported by Cloninger et al [4]. Within the depressed group, the significant correlations related HA with SD and ST, RD with C, P with SD and C, and SD with C and ST. The HA scale negatively correlated with SD. This relationship may imply that the anxious subjects have more difficulties in choosing goals and personal values and that they do not accept themselves [4,5]. The C scale positively correlated with RD, P, and SD, indicating a connectedness and an interpersonal relationship. Moreover, ST scores were reported to have a positive correlation with HA and SD. Other TCI scales displayed weaker correlations among themselves, and similar correlations were reported in previous studies [35,36]. Many studies in this area have used populations of patients who are heterogeneous in depressive subtype, age, sex, and ethnicity. One advantage of the present study over previous

work is the sample selection. All participants are selected from a socially, economically, and educationally homogenous population. One possible confounding factor is that antidepressant therapy contributes to the differences in mean personality scores between patients and controls. There are very little data currently available in this area, although in one study, selective serotonin reuptake inhibitors were suggested to exert effects on personality characteristics that are independent of clinical treatment response [11]. In this study, all depressed patients were evaluated, and scales were administered at baseline, before the initiation of a treatment. The limitations of this study must be emphasized. First, personality and depression were measured at a single time. Longitudinal studies are required to demonstrate whether the personality dimension of HA is a state or trait factor in depression. Second, it should be acknowledged that the study was carried out with a relatively small sample. Therefore, the conclusions should not be considered definitive, and further studies should be conducted with larger patient samples. In conclusion, the study confirms a link between depression and HA dimension of the TCI and suggests additional relationships with the character dimension of SD and the temperament dimension of NS of the Cloninger model of personality. Possibly, the combination of high HA with low SD is specific to depression, although further studies are clearly required to explore this possibility further. Acknowledgment The authors would like to thank Jennifer G. Schnellmann, PhD, ELS, for her assistance with editing the manuscript. The preliminary results of this study were previously presented at the 17th European College of Neuropsychopharmacology Congress, Stockholm, Sweden, October 2004. References [1] Akiskal HS, Hirschfield R, Yerevanian B. The relationship of personality to affective disorders. Arch Gen Psychiatry 1983;40: 801-10. [2] Hirschfeld RMA, Shea MT, Holzer CE. Personality dysfunction and depression. In: Honing A, van Praag HM, editors. Depression: neurobiological, psychopathological and therapeutic advances. New York: John Wiley; 1997. p. 327-41. [3] Hansenne M, Reggers J, Pinto E, Kjiri K, Ajamier A, Ansseau M. Temperament and character inventory (TCI) and depression. J Psychiatr Res 1999;33:31-9. [4] Cloninger CR, Svrakic DM, Przybeck TR. A psychological model of temperament and character. Arch Gen Psychiatry 1993;50:975-90. [5] Cloninger CR, Przybeck TR, Svrakic DM, Wetzel RD. The Temperament and Character Inventory (TCI): a guide to its development and use. Washington University, St Louis (Mo): Center for Psychobiology of Personality; 1994. [6] Matsudaira T, Kitamura T. Personality traits as risk factors of depression and anxiety among Japanese students. J Clin Psychol 2006;62(1):97-109. [7] Kose S. A psychobiological model of temperament and character: TCI. New Symp 2003;41(2):86-97.

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