The influence of temperament and character on functioning and aspects of psychological health among people with schizophrenia

European Psychiatry 19 (2004) 34–41 www.elsevier.com/locate/eurpsy

Original article

The influence of temperament and character on functioning and aspects of psychological health among people with schizophrenia Mona Eklund a,*, Lars Hansson b, Anita Bengtsson-Tops b a

Division of Occupational Therapy, Department of Clinical Neuroscience, Lund University, P.O. Box 157, 22100 Lund, Sweden b Division of Psychiatry, Department of Clinical Neuroscience, Lund University, P.O. Box 157, 22100 Lund, Sweden Received 15 January 2002; received in revised form 7 January 2003; accepted 25 July 2003

Abstract Research findings that link personality factors to functioning and symptoms in schizophrenia are inconsistent, and further studies are needed within the area. The purpose of this study was to investigate how personality, as measured by the Temperament and Character Inventory (TCI), was related to demographic factors, subtypes of diagnoses, level of functioning, and aspects of psychological health, including sense of coherence, perceived control, and self-esteem, among people with schizophrenia. Subjects were 104 individuals, aged 20–55 years, in psychiatric outpatient care. The results indicated that personality was not related to subtypes of diagnoses or demographic characteristics of the respondents, but to level of functioning and all aspects of psychological health. Especially self-directedness distinguished three groups of functioning and was highly correlated with the different aspects of psychological health. The article discusses how knowledge of schizophrenic patients’ personality structure might be used for tailoring psychiatric treatments. © 2003 Elsevier SAS. All rights reserved. Keywords: Personality; Functioning; Health; Sense of coherence; Mastery; Schizophrenia

1. Introduction The interest in personality vs. schizophrenia has been enormous ever since the days of Bleuler and Kraepelin [1]. Studies have indicated that personality variables may predict later onset of schizophrenia [2,3] as well as short-term course of schizophrenia [4]. Personality factors may also distinguish recovered patients with schizophrenia from non-recovered [5] and explain variability in insight [6] and work performance [7]. Kentros et al. [8] stated that personality profiles tend to be stable over time, especially in individuals with schizophrenia presenting negative symptoms, and appear to be trait-like. The results of another study by this group [9] indicated that personality traits influence perceptions of quality of life in patients with schizophrenia. Thus, there is evidence that personality in persons with schizophrenia is related to aspects of functioning and wellbeing. This type of knowledge seems important for interventions where the ambition is to individualize treatment according to personality differences in clients. However, no conclusive results about * Corresponding author. E-mail address: [email protected] (M. Eklund). © 2003 Elsevier SAS. All rights reserved. doi:10.1016/j.eurpsy.2003.07.008

personality, functioning, and aspects of health and wellbeing have been presented as yet, and further research about associations between these factors is needed. Functioning is used as an umbrella term in the International Classification of Functioning, Disability and Health (ICF) to describe possible consequences of a disease for the levels of body functions and of activities and participation [10]. Further components in the ICF are personal factors and the environment, and all components interact in a dynamic way. Mental health is defined as a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, and can work productively and fruitfully [11], and it may be viewed as the result of the dynamic interaction between the components of the ICF. According to the ICF, personal factors may influence functioning at any level, and the focus of the present study is on the relationship of personality to functioning on the body functions level and to different aspects of psychological health. There are different theoretical approaches to personality, one of which is the psychobiological model of personality developed by Cloninger and colleagues [12–14], which was selected as a basis for this study. The model is based on seven

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dimensions or factors. There are four temperament factors—novelty seeking, harm avoidance, reward dependence, and persistence—which are considered to be stable throughout life. Three character factors—self-directedness, cooperativeness, and self-transcendence—mature in response to social learning and life experiences. These dimensions are assessed by means of the Temperament and Character Inventory (TCI) [14]. This allows for comprehensive description of individual differences in feelings, thoughts, and actions, and has been suggested as useful for both clinical assessment and treatment planning [15]. Personality disorders [14,16,17] and mood disorders [18] are psychiatric diagnostic groups that have been frequently focused on in previous research proceeding from the psychobiological model. The psychobiological model may offer an interesting theoretical background for the study of schizophrenia and personality, since it takes into account both factors that are stable throughout life and traits that mature and develop with experiences. Moreover, it has been suggested as particularly relevant in schizophrenia [19], since there is empirical evidence that each of the temperament dimensions reflects the regulation of brain activity by the neurotransmitter systems dopamine, serotonine, and noradrenaline [13,19]. Very few studies have used the model with people with schizophrenia; however, Stompe et al. [20] found that patients with schizophrenia or a schizophrenia spectrum disorder scored higher on harm avoidance than both people with another psychiatric disorder and healthy controls. Guillem et al. [19] revealed that persons with schizophrenia differed from healthy controls on three out of four temperament dimensions, especially on harm avoidance, and on two out of the three character dimensions, particularly on self-directedness. They also showed that psychiatric symptoms were more associated with the character dimensions than the temperament dimensions. In another study, Van Ammers et al. [21] found a correlation between novelty seeking and use of alcohol, cannabis, nicotine, and caffeine among individuals suffering from schizophrenia. A study by Hansson et al. [22] indicated that especially self-directedness was important in determining self-rated global quality of life in patients with schizophrenia. Most of what is known so far about personality and schizophrenia [2–9] is based on other estimates of personality than the TCI. Previous research on the psychobiological model, however, indicates that temperament and character may be valuable factors when trying to reveal what contributes to the well-documented heterogeneity in persons with schizophrenia, which in turn is important to better understand and assist this group. Work on temperament, character, and schizophrenia has only just begun, but the results so far serve as an impetus for further research. Whether level of functioning and psychological health in this group are related to temperament factors, which are considered to be stable throughout life, or character factors, which mature in response to social learning and life experiences, or both, would

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be interesting knowledge for shedding light on the abovementioned heterogeneity and for developing and refining treatment strategies. Thus, this study aimed to: • Give a description of personality factors according to the TCI among a sample of patients with schizophrenia or schizoaffective disorder and investigate the relationships of the seven TCI dimensions to demographic factors and subtypes of diagnoses. • Investigate whether the TCI dimensions differed between subgroups of the sample based on level of functioning. It was hypothesized that they would differ on both temperament and character dimensions, especially on harm avoidance and self-directedness. • Finally, associations between the dimensions of TCI and variables related to psychological health—sense of coherence, sense of control, and self-esteem—were explored.

2. Subjects and methods 2.1. Selection procedure The criteria set for selection of subjects were a diagnosis of schizophrenia, schizophreniform disorder, or schizoaffective disorder according to DSM-IV [23] and an age of 20– 55 years. Samples were selected from two populations. The first sample was selected from a register comprising the most recent visits to psychiatric outpatient units in a geographically defined catchment area in a Swedish city. Those patients that had visited the units within the past 12 months, 119 individuals, were identified and asked to participate. A dropout of altogether 45 individuals, who did not want to participate (n = 40) or did not turn up at the interview (n = 5), resulted in a participation rate of 62%. There were no differences regarding sex or age between the dropouts and the participants. The dropout analysis revealed no statistically significant differences with respect to diagnostic subgroups of patients—hebephrenic, catatonic, residual, and undifferentiated schizophrenia classified into one subgroup, patients with paranoid schizophrenia into a second group, and those with schizophreniform disorder or a schizoaffective disorder forming a third subgroup. The second sample was added to increase power of the study. It was drawn from a cohort of patients participating in a longitudinal study [24] having a number of instruments in common with those used in the first sample, to which the TCI was added in a second wave of interviews. This cohort was originally randomly selected from a case register using the same inclusion criteria as in the first sample, except for age. Out of 94 patients, participating in this second part of the study, 71 fulfilled the criteria of age 20–55 years. Nineteen of these patients were judged by the interviewer not to be able to complete the TCI, because of incoherence or fatigue, leaving 52 patients available for this part of the interview. Thus, there was an extra selection criterion for this sample. Eight patients

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were not willing to participate, and one patient interrupted the interview. Accordingly, this sample finally consisted of 43 patients, a participation rate of 61% as calculated on those who fulfilled the criteria. No differences were found between participants and dropouts concerning age, sex, or diagnostic subgroup. Tests for differences between the samples indicated that they did not differ in age, gender, psychosocial functioning, and diagnosis, using the same criteria as above. As was expected from the extra selection criterion in sample two, the second sample showed less psychopathology (P = 0.001, as measured by the Brief Psychiatric Rating Scale—see Section 2.3). This difference between the samples was not considered a rationale for analyzing them separately and further on they are treated as one sample in this study. The study was based on informed consent, and a research ethics committee approved the project. The primary contact person of each patient took the initial contact and asked whether (s)he agreed to participate in the study. Subsequently, the patient received written and oral information about the study from the project team. No one in the research team was involved in the care of the patients. 2.2. Subjects The final sample consisted of 117 individuals with a mean age of 43 years, ranging from 20 to 55 years. Another 13 individuals were excluded due to an unacceptably high internal loss of data in the personality inventory (internal loss of data in >10% of the items), leaving 104 individuals included in the present part of the study. 2.3. Instruments A Swedish translation [25] of the short version of TCI, TCI-125 [26] was used. This short version allows for analyses of the four temperament and the three character dimensions, but since a reduced number of items always jeopardizes validity, we chose not to analyze subscales of these dimensions. TCI is a self-report measure, but in this study, the administration mode had to be modified due to the patients’ poor condition. The test administrator read the statements aloud, sometimes rephrasing the item somewhat if the patient was not able to understand. The test administrator also assisted some of the patients in marking yes or no in the form, but was careful never to force a response. Functioning was assessed as an index composed by three well-known instruments describing body functioning according to the ICF. (1) Psychopathology was assessed by means of the Brief Psychiatric Rating Scale (BPRS) [27,28]. It consists of 18 items, which are rated on a seven-point scale by an observer on the basis of an interview. Good interobserver and intra-observer reliability has been demonstrated. (2) Global Assessment of Functioning (GAF) [23] was employed to estimate global psychosocial functioning. It

forms a single observer rating on a 100-point scale, where 100 indicates not only absence of psychopathology, but also positive mental health. The scale is divided into 10 operationalized intervals and the exact rating is made relative to the two adjacent intervals. GAF is a slightly modified version of the Global Assessment Scale, which has acceptable validity and reliability [29]. (3) Affect balance was assessed by means of scales that are included in the Lancashire Quality of Life Profile (LQOLP) [30]. The test as a whole is administered as a structured interview, and the affect balance scale is based on the respondent’s self-ratings. The LQOLP as a whole has demonstrated good internal consistency and test– retest reliability [31,32]. An index is generally considered a more robust and reliable estimate of a phenomenon than a single scale [33], which gave rise to the idea of creating an index based on these instruments. The index was created as a sum of z-scores from the instruments, and a test of internal consistency resulted in a Cronbach’s alpha coefficient of 0.81, suggesting that use of this index was justified. The Sense of Coherence (SOC) scale [34,35] was used as a measure of psychological health. According to Antonovsky the sense of coherence indicates how well a person manages stress and stays healthy [34]. Comprehensibility, manageability, and meaningfulness are constructs that compose the sense of coherence. In the SOC instrument the respondents rate questions reflecting these constructs on a 7-point scale with two anchoring responses (e.g., never and very often). The instrument has proven to be valid and reliable [34,36], also for persons with schizophrenia [37]. A short version with 13 items, shown to have the same properties as the original 29-item scale [34,38], was used. Perceived control was measured by means of two selfrated constructs—mastery and locus of control. Mastery is defined as “the extent to which people see themselves as being in control of the forces that importantly affect their lives” (p. 340) and is measured by a seven-item scale with four rating alternatives where 4 indicates the highest level of mastery [39]. The scale has been found empirically distinct and unidimensional and to have good internal consistency [40]. The locus of control (LOC) scale was constructed by Rotter [41] and refers to whether an individual perceives reinforcements to be a function of his own actions (internal [I] control) or externally determined (external [E] control). The LOC scale includes a number of filler items, but the target construct is the I–E construct [42]. Andersson examined the dimensionality of the LOC scale and presented eight items that had a factor loading of +/– 0.40 with the I–E construct. The present study used those items, which were rated on a 4-point scale where 4 indicated internal locus of control. This scoring procedure is in accordance with a later Swedish development of the instrument [43]. The LOC scale has a fair internal consistency and test–retest reliability [41]. A correlation coefficient of 0.62 (P = 0.000) between mastery and LOC, corresponding to a shared variance of 38%, indicated that the two ways of measuring control were related, but yet different concepts.

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The self-esteem scale, originally developed by Rosenberg [44], was used to measure another aspect of psychological health. It has been shown to have acceptable internal consistency [30]. 2.4. Data analyses The respondents were divided into three equal groups based on the index of functioning, thus, forming groups of high (n = 35), middle (n = 34), and poor (n = 35) functioning. Differences between subgroups were based on one-way ANOVA with Scheffé’s post hoc test. A discriminant analysis, enter method, was employed to explore how the TCI could correctly predict which group of functioning the respondents belonged to. Pearson’s correlations were used to investigate associations between variables. Stepwise regression analyses were used to test for which TCI variables predicted the different aspects of psychological health. The raw scores of the TCI accounted for are not based on sum scores for each patient as in most TCI studies, but as proportion of maximum score (cf. [14]) to better reflect relativity in profiles. The software used was the SPSS program, version 10.0 [45].

3. Results 3.1. Characteristics of the respondents Among the 104 subjects included in the study there were 39 women (38%) and 65 men (62%). Most respondents (85%) were native Swedes, unmarried (66%) or widowed/divorced (23%), and had no children (76%). The most common accommodation was independent living in an apartment (78%), and 9% of the respondents lived in group homes. Mean age when leaving school was 18 years, range 9–31 years. Presently, most of the subjects had a sick or disability pension. Eighteen individuals (16%) said that they had some kind of employment. The predominant diagnostic subgroup was paranoid schizophrenia (47%). The other diagnoses were schizoaffective disorder (16%), undifferentiated schizophrenia (14%), disorganized schizophrenia (10%), residual schizophrenia (5%), schizophreniform disorder (4%), schizophrenia not specified (3%), and catatonic schizophrenia (1%). At the time of data collection, all subjects were in regular contact with psychiatric services. Mean age for first psychiatric hospitalization was 25 years, ranging from 2 to 51. Five individuals had never been hospitalized.

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resulted in no difference on any dimension (P-values ranging from 0.32 to 0.91). Nor were there any differences between groups according to civil status, married and widowed people forming one group and never married and divorced forming another (P-values ranging from 0.16 to 0.79) or between those with and without children (P-values ranging from 0.18 to 0.95). Correlations between age and the TCI factors showed a negative association between age and novelty seeking (rs = – 0.28, P = 0.005), but no other statistically significant relationships appeared (P-values ranging from 0.13 to 0.99). No correlations were found between age at first hospitalization and any of the TCI dimensions (P-values ranging from 0.13 to 0.97). 3.3. TCI, psychopathology, and functioning No difference was found on any dimension between subgroups of the sample according to diagnosis—hebephrenic, catatonic, residual, and undifferentiated schizophrenia classified into one subgroup, patients with paranoid schizophrenia into a second group, and those with schizophreniform disorder or a schizoaffective disorder forming a third subgroup (P-values ranging from 0.07 to 0.97). However, dividing the sample into three groups of functioning revealed differences on harm avoidance (P = 0.000), persistence (P = 0.029), and self-directedness (P = 0.000). Subsequent post hoc tests with correction for multiple comparisons revealed that on harm avoidance, the poor and the middle group scored higher than the high functioning group, while there was no statistically significant difference between the poor and the middle group. Regarding persistence, the only statistically significant difference was between the poor and the high functioning group, the poor scoring lower. On selfdirectedness, all three groups differed significantly from each other; the poorer functioning having the lowest score on self-directedness. No differences were found in novelty seeking, reward dependence, cooperativeness, or self-transcendence. Fig. 1 presents the groups’ mean scores on the TCI.

3.2. TCI and demographic characteristics of the respondents No gender differences were found on any of the TCI dimensions (P-values ranging from 0.13 to 0.99). Similarly, a grouping by ethnicity into native Swedes and immigrants

Fig. 1. Mean scores on the TCI dimensions (the scale indicates percentage of maximum score).

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Table 1 Results from regression analyses with different aspects of psychological health as dependent variables Beta

R2 change

Significance of F change

Sense of coherence (SOC) Self-directedness

0.701

0.49

0.000

Locus of control (LOC) Self-directedness

0.455

0.21

0.000

Mastery (1) Self-directedness (2) Harm avoidance

0.548 –0.263

0.52 0.04

0.000 0.003

Self-esteem (1) Self-directedness (2) Harm avoidance (3) Self-transcendence

0.5 –0.255 0.165

0.43 0.06 0.02

0.000 0.001 0.027

A discriminant analysis with group of functioning as dependent variable and the TCI dimensions as independent variables correctly predicted the groups for 77% of the poor functioning and 77% of the high functioning individuals, while 44% of those belonging to the middle group were correctly predicted. 3.4. TCI and psychological health The TCI factors were entered into stepwise regression analyses with each of the variables indicating psychological health as dependent variables. As shown in Table 1, selfdirectedness entered in the first step of all analyses and explained substantial proportions of the variation, especially in mastery, sense of coherence, and self-esteem. The variables that entered in a second or third step explained only a minor proportion of the total explained variance.

4. Discussion This study showed that personality as measured by the TCI, especially self-directedness and harm avoidance, was strongly related to functioning, which confirmed our hypothesis. This is in accordance with Lysaker et al. [46], who found that individual differences in personality were related to psychopathology. Furthermore, the results indicated that personality was not related to diagnosis and most sociodemographic characteristics. One exception was that higher levels of novelty seeking were associated with lower age, which replicated earlier findings [20]. According to the regression analyses, self-directedness alone explained most of the variance in the variables reflecting psychological health. Cloninger et al. [47] have demonstrated that people low on self-directedness are at risk of different psychiatric disorders, such as depression and paranoid reactions, depending on how self-directedness is combined with other character traits. However, the TCI has been used very sparsely among pa-

tients with schizophrenia and, to our knowledge, no previous study has focused on the relationship of character and temperament to functioning and health. Therefore, that selfdirectedness is important for level of functioning among people with schizophrenia is new knowledge, implying some clinical considerations that will be touched upon later on in this section. It is interesting that no differences on the TCI dimensions appeared as to subgroup of diagnosis. This is not surprising, however, since axis one of the DSM system is built up of course of illness and symptoms, deliberately excluding personality organization [47], which is considered in axis two [23]. The finding is also consistent with earlier findings of difficulties in demonstrating personality differences even between different main diagnoses [48,49], but it differs from some previous studies using a five-factor model of personality, which have demonstrated differences between people with schizophrenia and healthy controls [1] and between schizophrenia patients and other diagnoses [50]. 4.1. Personality and functioning There was a considerable variability in the TCI dimensions that could be explained by the level of functioning among the subjects. A high, a middle, and a poor group of functioning showed substantially different profiles in the present study, depending mainly on divergent levels of harm avoidance and self-directedness, but also persistence. These were three of the five dimensions that separated persons with schizophrenia from healthy controls in the study by Guillem et al. [19]. Furthermore, the discriminant analysis correctly predicted a large proportion of the poor functioning and the high functioning individuals, while a more modest proportion, somewhat higher than chance agreement, of the middle group was correctly predicted. This indicates that the TCI as a whole could identify poorer and better functioning schizophrenic patients, but not a middle group. A Swedish study of a normal population was published a few years ago [25]. A comparison with those results indicates that the profile of the high functioning group of the present study was quite similar to that of the normal population, except for selftranscendence where both the high and the poor group of functioning in the schizophrenia sample appeared to score higher. These are tentative conclusions, however, based on separate studies, and need to be tested further. Another parallel may be drawn to the study by Guillem et al. [19] showing that symptom dimensions were differently associated to the TCI factors. Their study was an important contribution in revealing sources of heterogeneity in the target group. However, separating the group of persons with schizophrenia into subgroups according to functioning, as in the present study, may have revealed another aspect of heterogeneity, not touched upon in their study. An issue related to the focus of this study was investigated by Skodol et al. [51]. They compared psychosocial functioning in different groups of personality disorder and found that

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patients with schizotypal disorder and borderline had significantly more impairment at work and in social relationships than patients with other types of personality disorder. Just as in the present study, this author group found that personality was a significant source of functioning. 4.2. Clinical implications of the findings Cloninger and Svrakic [15] emphasized that a certain level on a temperament or character dimension is not decisive of a person’s personality, and that the combination of different levels, or the profile, is of more significance. The combination of higher self-directedness and lower harm avoidance, which separated the three groups of functioning and according to the regression analyses distinguished higher levels of mastery and self-esteem in this study, has previously been regarded as an adaptive combination of personality traits, although in a different clinical group [52]. However, the fundamental personality abnormalities underlying psychoses seem difficult to specify [47]. Temperament and character configurations are related in a complex, nonlinear way [53], but how certain constellations of combined temperament and character traits should be interpreted more precisely seems not yet fully developed. According to the theory, though, a low level of self-directedness, which appeared as a risk factor for low scores on functioning and health, is a result of unproductive patterns of self-object relationships and detrimental life circumstances. Harm avoidance, which also proved to be of importance to some aspects of functioning and health, is on the other hand considered to be a temperament factor, fairly stable throughout life. Those people with schizophrenia who exhibit a low level of self-directedness and a high level of harm avoidance might be an especially vulnerable group for which efforts should be made to provide a supportive and reliable environment with stable and reinforcing object relations. This could counteract a social behavior that otherwise might lead to additional lowering of self-directedness. Such interventions should emphasize interpersonal contacts, self-object differentiation, and positive social-learning models (cf. [53]). Most likely, there are several existing programs that fulfill this purpose, and testing patients’ personality structure would increase the possibilities to direct patients to the most pertinent type of care. Programs focusing on social skills training, e.g., the concept developed by Liberman and Corrigan [54], might be more effective with patients showing a combination of low selfdirectedness and high harm avoidance. However, the Liberman concept builds upon group-based training modules taking place in care settings, supplemented with home lessons, and this disadvantaged group of patients would probably profit from more individualized support in natural social contexts. For example, an intensive case management system with individual training in the patient’s home environment or in societal situations could provide opportunities for interpersonal contacts and positive social-learning models, in turn paving the way for self-object differentiation. These assump-

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tions, generated from this explorative study, may serve as hypotheses to be tested in future research. 4.3. Assessing personality in schizophrenia—methodological aspects This seems to be one of the first published studies on temperament, character and schizophrenia. The TCI requires the respondent to understand the statements and make a decision of false or true as applied to themselves. Many persons with schizophrenia do not meet these requirements, and the validity of their responses has to be estimated. This was obvious from the present study, which had to accept a fairly large attrition rate because of these difficulties. Unfortunately, the information about the dropout patients was limited, but it is known from the second sample that the most severely ill patients were excluded. Similarly, those who had to be excluded because of more than 10% unanswered items in the TCI were patients with severe psychopathology. Thus, the present study comprised a spectrum of moderately ill schizophrenic patients, not well enough to manage without ongoing psychiatric outpatient care, but not worse than that they were able to complete the TCI with some assistance. How to be able to include the more severely ill patients in a study like this is a precarious question. They were excluded to enhance the validity of the measurement, which on the other hand lowered the representativity. However, the opposite decision, to prioritize representativity at the expense of the validity, would also be conceivable and would lead to the inclusion of more sick patients. In fact, the consequences of such a decision were tested in this study by setting an alternative limit, <25% of unanswered items in the TCI, for exclusion. This meant that seven more individuals, six of whom belonged to the low-functioning subgroup, were included. The result pattern remained the same; only minor changes in P-values occurred. The problems with using the TCI illustrate the general dilemma of assessing personality in persons with schizophrenia. It is an important area to study in order to gain more knowledge about how to encounter and treat these patients, but at the same time the validity of the personality assessment for this group must always be questioned. The question has been raised what personality really means in a patient with schizophrenia. However, the fact that the result remained the same whether the limit for inclusion in the analyses was set at <10% or <25% unanswered items indicates the overall validity of the TCI for the target group. Moreover, the psychobiological model is particularly suitable with persons with schizophrenia [19], since it distinguishes between the genetically determined temperament dimensions and the character dimensions, which seem more closely related to symptom profiles and, as indicated in the present study, to functioning and psychological health. 5. Conclusion Although research that links personality factors to functioning, symptoms, and aspects of health in schizophrenia

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has existed for decades, the results so far are inconsistent and it is not yet possible to formulate any conclusive principles. The present study approached the hitherto undisclosed relationship between temperament and character traits and certain aspects of schizophrenia, namely, functioning and psychological health. Especially self-directedness was strongly associated with these aspects. The clinical implications of these results are that psychiatric treatments should be differentiated, and that patients exhibiting a combination of low self-directedness and high harm avoidance need individualized support in natural social contexts, with opportunities for interpersonal contacts and positive social-learning models, in turn facilitating further self-object differentiation.

Acknowledgements We are grateful to Ulrika Bejerholm, OTR, B.Sc., for performing part of the data collection and to the Psychiatric Services of Malmö and the Vardal Foundation for financial support for the study.

References [1]

[2]

[3]

[4] [5]

[6]

[7]

[8]

[9]

[10] [11] [12] [13]

Gurrera RJ, Nestor PG, O’Donell BF. Personality traits in schizophrenia. Comparison with a community sample. J Nerv Ment Dis 2000; 188:31–5. Malmberg A, Lewis G, David A, Allebeck P. Premorbid adjustment and personality in people with schizophrenia. Br J Psych 1998;172: 308–13. Carter JW, Parnas J, Cannon TD, Schlusinger F, Mednick SA. MMPI variables predictive of schizophrenia in the Copenhagen High-Risk Project: a 25-year follow-up. Acta Psychiatr Scand 1999;99:432–40. Dingemans PMAJ, Lenior ME, Linszen DH. Personality and schizophrenic relapse. Int Clin Psychopharmacol 1998;13(Suppl 1):S89–95. Torgalsboen A-K. Comorbidity in schizophrenia: a prognostic study of personality disorder in recovered and non-recovered schizophrenia patients. Scand J Psychol 1999;40:147–52. Lysaker PH, Bell MD, Bryson G, Kaplan E. Personality as a predictor of the variability of insight in schizophrenia. J Nerv Ment Dis 1999; 187:119–22. Lysaker PH, Bell MD, Kaplan E, Bryson G. Personality and psychosocial functioning in schizophrenia: the association of extraversion and neuroticism to deficits in work performance. Psychiatry Res 1999;80:61–8. Kentros M, Smith TE, Hull J, McCee M, Terkelsen K, Capalbo C. Stability of personality traits in schizophrenia and schizoaffective disorder: a pilot project. J Nerv Ment Dis 1997;185:549–55. Kentros MK, Terkelsen K, Hull J, Smith TE, Goodman M. The relationship between personality and quality of life in persons with schizoaffective disorder and schizophrenia. Qual Life Res 1997;6: 118–22. World Health Organization. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001. World Health Organization. Face sheet no. 220. Geneva: World Health Organization; 1999. Cloninger CR. A systematic method for clinical description and classification of personality variants. Arch Gen Psych 1987;44:573–88. Cloninger CR. The genetics and psychobiology of the seven-factor model of personality. In: Silk KR, editor. Biology of personality disorders. Washington (DC): American Psychiatric Press; 1998. p. 63–92.

[14] Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psych 1993;50:975–90. [15] Cloninger CR, Svrakic DM. Integrative psychobiological approach to psychiatric assessment and treatment. Psychiatry 1997;60:120–41. [16] Bejerot S, Schlette P, Ekselius L, Adolfsson R, von Knorring L. Personality disorders and relationship to personality dimensions measured by the Temperament and Character Inventory in patients with obsessive-compulsive disorder. Acta Psychiatr Scand 1998;98:243–9. [17] Svrakic DM, Draganic S, Hill K, Bayon C, Przybeck TR, Cloninger CR. Temperament, character, and personality disorders: etiologic, diagnostic, treatment issues. Acta Psychiatr Scand 2002; 106:189–95. [18] Hansenne M, Reggers J, Pinto E, Kjiri K, Ajamier A, Ansseau M. Temperament and Character Inventory TCI and depression. J Psychiatr Res 1999;33:31–6. [19] Guillem F, Bicu M, Semkovska M, Debruille JB. The dimensional symptom structure of schizophrenia and its association with temperament and character. Schizophr Res 2002;56:137–47. [20] Stompe T, Willinger U, Fischer G, Meszaros K, Berger P, Strobl R, et al. The unified biosocial model of personality in schizophrenia families and controls. Psychopathology 1998;31:45–51. [21] Van Ammers EC, Sellman JD, Mulder RT. Temperament and substance abuse in schizophrenia: is there a relationship? J Nerv Ment Dis 1997;185:283–8. [22] Hansson L, Eklund M, Bengtsson-Tops A. The relationship of personality dimensions as measured by the TCI and quality of life in individuals with schizophrenia or schizoaffective disorder living in the community. Qual Life Res 2001;10:133–9. [23] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): APA; 1994. [24] Bengtsson-Tops A, Hansson L. Clinical and social needs of schizophrenic outpatients. Relationship of needs and subjective quality of life. Soc Psychiatry Psychiatr Epidemiol 1999;34:513–8. [25] Brändström S, Schlette P, Przybeck TR, Lundberg M, Forsgren T, Sigvardsson, et al. Swedish normative data on personality using the Temperament and Character Inventory. Compr Psych 1998;39:122–8. [26] Cloninger CR, Przybeck TR, Svrakic DM, Wetzel RM. The Temperament and Character Inventory TCI: a guide to its development and use. St. Louis (MO): Center for Psychobiology of Personality, Washington University; 1994. [27] Kolakowska T. BPRS. Oxford: Oxford University; 1976. [28] Andersen J, Larsen JK, Schultz V, Nielsen BM, Kørner A, Behnke K, et al. The Brief Psychiatric Rating Scale. Dimension of schizophrenia—reliability and construct validity. Psychopathology 1989;22:168–76. [29] Endicott J, Spitzer R L, Fleiss JL, Cohen J. The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psych 1976;33:766–71. [30] Oliver J, Huxley P, Bridges K, Mohamad H. Quality of life and mental health services. London: Routledge; 1996. [31] Hansson L, Svensson B, Björkman T. Quality of life of the mentally ill. Reliability of the Swedish version of the Lancashire Quality of Life Profile. Eur Psych 1998;13:231–4. [32] Oliver JPJ, Huxley PJ, Priebe S, Kaiser W. Measuring the quality of life of severely mentally ill people using the Lancashire Quality of Life Profile. Soc Psychiatry Psychiatr Epidemiol 1997;32:76–83. [33] Cook TD, Campbell DT. Quasi-experimentation. Design and analysis issues for field settings. Boston: Houghton Mifflin; 1979. [34] Antonovsky A. Unraveling the mystery of health. San Francisco: Jossey-Bass; 1987. [35] Antonovsky A. The structure and properties of the sense of coherence scale. Soc Sci Med 1993;36:725–33. [36] Langius A, Bjorvell H, Antonovsky A. The sense of coherence concept and its relation to personality traits in Swedish samples. Scand J Car Sci 1992;6:165–71. [37] Bengtsson-Tops A, Hansson L. The validity of Antonovsky’s sense of coherence concept in a sample of individuals with schizophrenia living in the community. J Adv Nurs 2001;33:432–8.

M. Eklund et al. / European Psychiatry 19 (2004) 34–41 [38] Langius A, Björvell H. Coping ability and functional status in a Swedish population sample. Scand J Car Sci 1993;7:3–10. [39] Pearlin LI, Menaghan EG, Lieberman MA, Mullan JT. The stress process. J Health Soc Behav 1981;22:337–56. [40] Marshall GN, Lang EL. Optimism, self-mastery, and symptoms of depression in women professionals. J Pers Soc Psychol 1990;59: 132–9. [41] Rotter JB. Generalized expectancies for internal versus external control of reinforcements. Psychol Monog: Gen Appl 1966;80:1–28. [42] Andersson G. Internal–external locus of control: some methodological notes on the research and a factor analysis of a revised I–E scale. Reports from the Department of Applied Psychology, 9. (Sweden): Göteborg University; 1975. p. 1–13 (1). [43] Eisemann M, Perris C, Palm U, Palm A, Perris H. LOC—presentation of a Swedish instrument for assessing locus of control. In: Perris C, Eisemann M, editors. Cognitive psychotherapy—an update. Umeå (Sweden): Department of Psychiatry, University of Umeå; 1988. p. 45–8. [44] Rosenberg M. Society and the adolescent self image. Princeton (NJ): Princeton University Press; 1965. [45] Norusis MJ. SPSS base 7.5 for Windows user’s guide. Chicago: SPSS Inc; 1997. [46] Lysaker PH, Bell MD, Kaplan E, Grieg TC, Bryson G. Personality and psychopathology in schizophrenia: the association between personality traits and symptoms. Psychiatry 1999;62:36–48.

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[47] Cloninger CR, Svrakic DM, Bayon C, Przybeck TR. Measurement of psychopathology as variants of personality. In: Cloninger CR, editor. Personality and psychopathology. Washington (DC): American Psychiatric Press; 1999. p. 33–65. [48] Greenblatt RL, Davis WE. Differential diagnosis of PTSD, schizophrenia, and depression with the MMPI-2. J Clin Psychol 1999;55: 217–23. [49] Oulis P, Lykouras L, Hatzimanolis J, Tomaras V. Comorbidity of DSM-III-R personality disorders in schizophrenic and unipolar mood disorders: a comparative study. Eur Psych 1997;12:316–8. [50] Bagby RM, Bindseil KD, Schuller DR, Rector NA, Young LT, Cooke RG, et al. Relationship between the five-factor model of personality and unipolar, bipolar, and schizophrenic patients. Psychiatry Res 1997;70:83–94. [51] Skodol AE, Gunderson JG, McGlashan TH, Dyck IR, Stout RL, Bender DS, et al. Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psych 2002;159:276–83. [52] Allgulander C, Cloninger RC, Przybeck TR, Brandt L. Changes on the Temperament and Character Inventory after paroxetine treatment in volunteers with generalized anxiety disorder. Psychopharmacol Bull 1998;34:165–6. [53] Cloninger CR, Svrakic NM, Svrakic DM. Role of personality selforganization in development of mental order and disorder. Dev Psychopathol 1997;9:881–906. [54] Liberman RP, Corrigan PW. Designing new psychosocial treatments for schizophrenia. Psychiatry 1993;56:238–48.