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The relationship between impulsivity and panic disorder-agoraphobia: The role of affective temperament
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The relationship between impulsivity and panic disorder-agoraphobia: the role of affective temperament Aslı Bes¸irli PII: DOI: Reference:
S0165-1781(17)31543-3 10.1016/j.psychres.2018.03.021 PSY 11253
To appear in:
Psychiatry Research
Received date: Revised date: Accepted date:
19 August 2017 27 December 2017 7 March 2018
Please cite this article as: Aslı Bes¸irli , The relationship between impulsivity and panic disorder-agoraphobia: the role of affective temperament, Psychiatry Research (2018), doi: 10.1016/j.psychres.2018.03.021
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Highlights: There is a relationship between impulsivity and panic disorder. There are correlations between affective temperament dimensions and impulsivity
Affective temperamental traits influence impulsivity.
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Aslı Beşirlia*
: Department of Psychiatry, University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, Şişli, İstanbul,Turkey
*Corresponding Author: Aslı Beşirli, MD
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THE RELATIONSHIP BETWEEN IMPULSIVITY AND PANIC DISORDERAGORAPHOBIA: THE ROLE OF AFFECTIVE TEMPERAMENT
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Department of Psychiatry, University of Health Sciences, Şişli Hamidiye Etfal Training and
Phone: (+90) 212 3735000
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Fax : (+90) 212 2240772
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Research Hospital, Halaskargazi Street, 34371- Şişli, İstanbul, Turkey
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E-mail: [email protected]
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ABSTRACT
There are opinions regarding that impulsivity may play a role in the pathogenesis of neuropsychiatric disorders. The aim of this study was to investigate the relationship between impulsivity and panic disorder (PD) in the patient group, to compare impulsivity and affective temperamental traits between patients and healthy controls and to investigate whether there is a relationship between impulsivity and affective temperamental traits. Participants comprised 70 patients with PD and 58 healthy volunteers. The panic agoraphobia scale (PAS), the Barratt impulsiveness scale (BIS-11) and the Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire (TEMPS-A) were applied. Patients have significantly higher scores in 2
ACCEPTED MANUSCRIPT affective temperament (except hyperthymic) and attentional impulsiveness subscales than the healthy controls. Positive and negative correlations were found between some PAS and BIS-11 scores as well as correlations between especially cyclothymic, hyperthymic, irritable and anxious subscale scores of the TEMPS-A and the BIS-11 scores in the patient group. The results of this study indicate a relationship between impulsivity and PD. The correlations found between affective temperament dimensions and impulsivity suggest how affective temperamental traits
Key Words: Panic disorder; impulsiveness; temperamental traits.
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1. Introduction
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may influence different impulsivity dimensions.
Impulsivity is a trait of both normal and pathological behavior, characterizing a transition from tendency to taking action. It is also a determinant of personal differences, psychiatric disorders, and related risk-taking behaviors (Chamorro et al., 2012; Dell'Osso et al., 2006). Some researchers
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believe that impulsivity may play a role in the pathogenesis of neuropsychiatric disorders. Impulsivity has been investigated in the study of many mental disorders, such as affective
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disorders, personality disorders, alcohol addiction, attention deficit hyperactivity disorder, and bulimia nervosa (Jakuszkowiak-Wojten et al., 2015a). According to Eysenck’s definition,
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extroverted impulsivity demonstrates a decision process that takes into account the results and risks of an action, whereas impulsivity of a psychotic degree does not consider risks (Eysenck et
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al., 1985).
The association between anxiety and impulsiveness is controversial, but it is conventionally
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considered that impulsiveness is inversely related to anxiety (Barratt, 1965; Askenazy et al., 2000). Some studies found no association between anxiety and impulsiveness (Askenazy et al., 2000; Apter et al., 1993; Lecrubier et al., 1995). However, there is large amount of data setting forth the comorbidity of anxiety disorders and impulse control disorders, or impulsivity (Preve et al., 2014; Del Carlo et al., 2013; Summerfeldt et al., 2004). In addition, individuals with impulse control disorder feel more anxiety and tension before their impulsive actions (Preve et al., 2014). However, it has been suggested that anxiety could be a protective factor against uninhibited,
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ACCEPTED MANUSCRIPT potentially dangerous behaviors and may be protective against impulsivity as well (Taylor et al., 2008). Askenazi et al. (2003) evaluated the level of anxiety and impulsivity in adolescents hospitalized for a number of behavioral problems (suicide attempts, aggressive behavior, substance poisoning, faulty behavior, and eating disorders). In this study, it has been stated that the comorbidity of anxiety and impulsivity with mood disorders is a strong risk predictor with regard to suicide
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attempts. In addition, the presence of anxiety in impulsive persons may lead to introverted aggressiveness instead of preventing behavioral dyscontrol. Impulsivity without anxiety has been found to be associated with antisocial behaviors, behavioral disorders, and aggressive behaviors directed toward others (Askénazy et al., 2003).
In many studies, it has been shown that bipolar patients with comorbid anxiety disorder are more
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impulsive compared to those without comorbid anxiety disorder (Del Carlo et al., 2013). Even though harm avoidance and behavioral inhibition are observed in anxiety disorders (Taylor et al., 2008), it has been suggested that patients with anxiety are more impulsive compared to healthy controls (Del Carlo et al., 2013).
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Epidemiological data indicate that panic disorder (PD) is one of the anxiety disorders that disrupts functionality the most (Nutt, 2011). The relationship between panic disorder and impulsivity has
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not been sufficiently investigated (Del Carlo et al., 2013). Although the presence of aggressive behavior has been shown in patients with PD in many studies (Korn et al., 1997; Pilowsky et al., 1999; Beck et al., 1991; Vickers and McNally, 2004), the relationship between PD and aggression
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has not been fully explained.
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Anxiety and impulsivity are two main risk factors for suicide (Pierò, 2010). Data regarding behaviors that are strongly related to impulsivity, such as unpremeditated suicide and aggression,
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have been reported in a small number of studies (Neufeld and O'Rourke, 2009; Pavlov et al., 2012; Gvion and Apter, 2011). In some studies of patients with PD, the ideation and attempt of murder have been reported to be higher (Korn et al., 1997; Weissman et al., 1989); whereas in some studies, it has been demonstrated that lifelong PD is not associated with increased suicide attempts and patients with PD that have a higher risk regarding suicide attempts have been shown to have other comorbid disorders (Vickers and McNally, 2004). In one study, it was reported that 31.7% of patients with PD had suicidal ideation during the last two weeks and that severity of panic symptoms, weak social support, youth, and alcohol use were 4
ACCEPTED MANUSCRIPT associated with suicidal ideation (Huang et al., 2010). However, although it is known that patients with PD have aggressive behavior (Korn et al., 1997; George et al., 1989), the relationship between PD and aggression has not been fully explained. Conventionally, temperament that emerges at an early age, and is partially affected by genetic structure, indicates stable behavior and emotional reactions (Tomassini et al., 2009). In the psychobiological model set forth by Cloninger et al. (1993), personality is divided into two halves,
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temperament and character. The most commonly used questionnaires in this model are the Tridimensional Personality Questionnaire (TPQ) and the Temperament and Character Inventory (TCI). In the TCI, 4 dimensions of temperament—novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence (P)—and 3 dimensions of character)—self-directedness (SD), cooperativeness (C), and self-transcendence)—have been defined (Cloninger et al., 1993).
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Akiskal et al. (2005) made a new arrangement by adding anxious temperament to the four types of temperament (depressive, hyperthymic, irritable, and cyclothymic) set forth by Kraepelin. To be able to examine temperament better, Akiskal developed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A) questionnaire for research and clinical purposes. The questionnaire, composed of 110 items, has been translated into more than 25 languages, and
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validity studies of most of them have been performed (Akiskal et al., 2005). In TEMPS-A, depressive and cyclothymic dimensions were associated with high HA, whereas hyperthymic and
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cyclothymic dimensions were associated with high NS (Maremmani et al., 2005). Even though there are many publications on temperament and mood disorders, there have been
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only a few systematic studies done regarding the relationship of anxiety disorder and temperament. In one of these publications, Tomassini et al. (2009) found that there was no
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significant difference regarding brief TEMPS-M scores between the two groups in their study that compared 45 patients with anxiety disorders and 56 patients with mood disorders (Tomassini et
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al., 2009).
Adult patients with PD have character profiles and temperaments showing a higher HA and lower SD as also defined by Cloninger (Wachleski et al., 2008; Perna et al., 1994), and it has been reported in cross-sectional studies that there is a relationship between anxiety symptoms or anxiety disorders and HA ( Brown et al., 1992; Jylhä and Isometsä, 2006). In the light of all these data, the aim of this study is to investigate the relationship between impulsivity and PD in the patient group, to compare impulsivity and affective temperamental traits 5
ACCEPTED MANUSCRIPT between patients with PD and healthy controls and to investigate whether there is a relationship between impulsivity and affective temperamental traits in patients with PD. My hypothesis has proposed that the relationship between impulsivity and PD might be affected by affective
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temperamental traits.
2. Methods
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2.1. Subjects
Seventy patients between the ages of 18 and 65 who were psychotropic drug-naive and presented
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to the psychiatry outpatient clinic, where they were diagnosed for the first time with PD with or without agoraphobia according to the DSM-5 (American Psychiatric Association, 2013) criteria.
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To form the control group, 58 healthy volunteers matching the patient group with regard to age, gender, education, occupation, marital status, and income were included in the study. Patients who
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were younger than 18 and older than 65 years of age; or were illiterate; still in a depressive, manic, or hypomanic episode; using illicit drugs, antidepressants, or dibenzodiazepines, etc.; who had
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cyclothymic disorder, dysthymic disorder, schizophrenia or other psychotic disorders, alcohol and substance use disorders, mental retardation, other somatic comorbidity, or any other conditions apart from anxiety disorder, such as neurological disease, serious heart, circulation, endocrine, or respiratory disease; or who did not agree to participate in the study were not included in the study. No urine drug test was performed. Patients’ self-reports were taken into consideration. Any other treatments such as psychotherapy or other concomitant treatment were not administered. The same criteria were considered as exclusion criteria for the healthy volunteers in the control group.
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ACCEPTED MANUSCRIPT The trial protocol was approved by the local ethics committee. Written informed consent was obtained from the patients after the purposes and course of conduct of the trial being planned was conveyed to the patients. 2.2. Procedures To determine the severity of the panic disorder, the panic agoraphobia scale (PAS) was applied. The PAS scale identifies 13 items grouped into 5 subscales: 1. panic attacks (frequency, severity,
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and duration), 2. agoraphobia (frequency, number, and relevance of situations), 3. anticipatory anxiety (frequency and severity), 4. disability (family, social relationships, and employment), and 5. worries about health (worries about health damage due to panic attacks and assumption of organic disease). Every subscore consists of its component scores, and the total score is obtained
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by summing up all subscores ( Bandelow et al., 1998).
Impulsivity was evaluated with the Barratt impulsiveness scale (BIS-11). The BIS-11 was used to assess three impulsiveness dimensions: attentional, motor, and nonplanning. The total score was determined by summing all items. The higher the score, the higher is the level of impulsivity (Summerfeldt et al., 2004; Patton et al., 1995; Vasconcelos et al., 2012).
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The Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire (TEMPS-A) questionnaire was used to evaluate temperamental traits. The TEMPS-A consists of 100
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dichotomous items assessing 5 temperament dimensions: depressive, cyclothymic, hyperthymic, et al. (2005).
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irritable, and anxious temperaments (Akiskal et al., 2005). It was translated into Turkish by Vahip
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2.3.Statistical analysis
Descriptive statistics were used to define continuous variables (mean, standard deviation, minimum, median, maximum). The comparison of independent and normally distributed two
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continuous variables was performed with Student’s t-test, and the comparison of the independent and nonnormal two variables was performed with the Mann-Whitney U Test. Chi-square (or where appropriate the Fisher Exact Test) was used to examine the relationship between categorical variables. Correlation between the continuous nonnormal variables was examined with Spearman’s correlation coefficient. The level of statistical significance was determined at 0.05. Analyses were performed using MedCalc Statistical Software version 12.7.7 (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2013).
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3. Results
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3.1. Sociodemographic characteristics of the patients and control groups There were no statistically significant differences between the patients and control groups with
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regards to age, gender, educational status, marital status, occupation, and income. The number of patients who were diagnosed with PD and comorbid agoraphobia was 60 (85.7%), and the number
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of patients diagnosed with PD only was 10 (14.3%) in the entire patient group (n = 70) (Table 1).
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3.2. Clinical scale scores of PD patients and healthy controls The depressive, cyclothymic, irritable, and anxious scores of the TEMPS-A and the attentional
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impulsiveness subscale scores of BIS-11 were statistically higher in the patient group than in the control group. The hyperthymic score of the TEMPS-A and the motor, nonplanning, and total impulsiveness subscale scores of the BIS-11 did not reveal a statistically significant difference between patients and the control group (Table 2). 3.3. Relationship between impulsivity dimensions and PAS items A negative and statistically significant correlation between PAS A1 (panic attacks, severity) and the BIS nonplanning subscale score (r =- 0.250, p = 0.037), a weak and statistically significant 8
ACCEPTED MANUSCRIPT correlation between PAS B2 (agoraphobia, number of situations) and the BIS attentional subscale score (r = 0.294, p = 0.013), a weak and statistically significant correlation between PAS B3 (agoraphobia, relevance of situations) and the BIS attentional subscale score (r = 0.315, p = 0.008), a weak, negative, and statistically significant correlation between PAS C1 (anticipatory anxiety, frequency) and the BIS motor subscale score (r = -0.248, p = 0.039), and a weak, negative, and statistically significant correlation between PAS D3 (disability; employment, housework) and the BIS nonplanning subscale score (r = -0.273, p = 0.022) were also found.
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There was no statistically significant correlation between the other scales (Table 3).
3.4. Relationship between the TEMPS-A scale sores and impulsivity dimensions in the patient group
There was a weak and statistically significant correlation between the cyclothymic score of the
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TEMPS-A and the attentional, motor, and total impulsiveness scores of the BIS-11 (r = 0.345, p<0.001; r = 0.291, p = 0.001; r = 0.221, p = 0.012, respectively), and there was a weak,
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negative, and statistically significant correlation between the cyclothymic score of the TEMPS-A
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and the nonplanning subscale score of the BIS-11 (r = -0.184, p = 0.037). A weak and statistically significant correlation between the hyperthymic score of the TEMPS-A
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and the motor, nonplanning, and total impulsiveness scores of the BIS (r = 0.232, p = 0.009; r = 0.204, p = 0.021; r = 0.304, p<0.001, respectively), a weak and statistically significant correlation
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between the irritable score of the TEMPS-A and the attentional, motor, and total impulsiveness scores of the BIS (r = 0.304, p <0.001; r = 0.208, p = 0.018; r = 0.220, p = 0.013, respectively), a weak and statistically significant correlation between the anxious score of the TEMPS-A and the attentional subscale score of the BIS. (r = 0.319, p < 0.001) were also found. No statistically significant correlation was found between the depressive score of the TEMPS-A and the BIS total and subscores (Table 4).
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4. Discussion
4.1. Symptomatological and Temperamental Assessment
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In this study, the depressive, cyclothymic, irritable, and anxious scores of the TEMPS-A were statistically significantly higher in the patient group when compared to the control group, whereas
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the hyperthymic score of the TEMPS-A did not show a statistically significant difference between the patient and control groups. The findings of this study are consistent with the findings of prior
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studies (Del Carlo et al., 2012; Perugi et al., 2011; Altınbaş et al., 2015).
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4.2. Assessment of Impulsiveness In this study, the attentional impulsiveness score of the BIS in the patient group was statistically
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higher as compared to the control group. Motor, nonplanning, and total BIS scores did not reveal a statistically significant difference between patients and the control group. Distinct from this study, Del Carlo et al. (2012) found that BIS total and all BIS subscores in patients with anxiety disorder were higher than in the control group (Del Carlo et al., 2012). In another study, it has been demonstrated that, similarly, the BIS total and all BIS subscores of PD patients were higher as compared to the control group (Del Carlo et al., 2013). Again in another study, the BIS total and attention and nonplanning scores of all patients in the anxiety disorder group have been reported to be higher as compared to the control group (Summerfeldt et al., 2004). Perugi et al. (2011), 10
ACCEPTED MANUSCRIPT found that in patients with various anxiety disorders (PD, obsessive compulsive disorder, social phobia, generalized anxiety disorder), the BIS total, attention, and motor scores were higher than the control group, and there was no statistically significant difference between the patient and control groups with regard to nonplanning scores (Perugi et al., 2011). 4.3. Assessment of the Relationship Between Panic Disorder and Impulsivity in the Patient Group
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The findings in literature investigating the relationship between PD and impulsiveness are inconsistent. In this study, both positive and negative correlations were found between some PAS and BIS subscores. In some studies, a positive correlation has been reported between anxiety disorder and impulsiveness (Del Carlo et al., 2013; Summerfeldt et al., 2004; Kashdan et al., 2008). In one study, the BIS was used on a group of patients with anxiety disorder (40 obsessive
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compulsive disorder, 37 PD, and 24 social anxiety disorder patients), and both total and attentional impulsiveness and nonplanning subscores were reported to be higher in the patient group than in the control group ( Summerfeldt et al., 2004). In another study, composed of 47 patients with different anxiety disorders (panic disorder, obsessive compulsive disorder, social phobia, generalized anxiety disorder), the BIS total score and all subscores thereof were significantly
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higher than those of the control group (Del Carlo et al., 2012).
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Correlation between the severity of PD and impulsiveness has been investigated in a few studies. In a study carried out by Jakuszkowiak-Wojten et al. (2015), the correlation between the PAS scores and the BIS-11 scores of 21 drug-free PD patients were investigated, and the results
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demonstrated a correlation between the attentional impulsiveness of BIS and PAS D3 (disability, employment, housework) and nonplanning of BIS and PAS E1 (worries about health damage)
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(Jakuszkowiak-Wojten et al., 2015b). In another study, researchers found that the BIS scores of patients with PD were higher than those of the control group, and there was a correlation between
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impulsiveness and cognitive functions (Jakuszkowiak-Wojten et al., 2013).
4.4. Assessment of the Relationship Between Impulsiveness and Temperament Scores in the Patient Group There was a weak and statistically significant correlation between the cyclothymic temperament score and the attentional, motor, and total impulsiveness scores of the BIS, and there was a weak, negative, and statistically significant correlation between the cyclothymic temperament score and 11
ACCEPTED MANUSCRIPT the nonplanning subscore of the BIS. In addition, a weak and statistically significant correlation was determined between the irritable temperament score and the attentional, motor, and total impulsiveness scores of the BIS in this study. A strong relationship between impulsiveness and cyclothymic and irritable temperament was also determined in a study they performed in patients with bipolar disorder (Tatlidil Yaylaci et al., 2014). A weak and statistically significant correlation between the anxious temperament score and the
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attentional impulsiveness score of the BIS has been found in this study. Also, there was a weak and statistically significant correlation between the hyperthymic score and the motor, nonplanning, and total impulsiveness score of the BIS. In their study, Tatlıdil Yaylacı et al. (2014) demonstrated that there was a moderate relationship between impulsiveness and an anxious temperament; however, distinct from this study, that there was no correlation between the
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hyperthymic temperament and impulsiveness. In addition, no relationship between depressive temperament scores and impulsiveness has been found in this study, whereas Tatlıdil Yaylacı et al. (2014) showed that there was a moderate relationship between depressive temperament and impulsiveness (Tatlidil Yaylaci et al., 2014). Similar to the findings of this study, Walsh et al. (2012) showed that impulsiveness was associated with cyclothymic, hyperthymic, and irritable
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temperaments (Walsh et al., 2012). It is suggested that the strong relationship between impulsiveness and cyclothymic and irritable temperaments was mainly related to irritability. In
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addition, the relationship between impulsiveness and anxious and depressive temperaments might
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be related to the feeling of subjective stress and anxiety (Tatlidil Yaylaci et al., 2014). In the TEMPS-A, depressive and cyclothymic dimensions were associated with high HA, whereas
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hyperthymic and cyclothymic dimensions were associated with high NS (Maremmani et al., 2005). NS signifies the activation level of exploratory activities. Persons with high NS scores perform
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exploratory activities more and have a tendency toward rapid decision-making and extravagance. In addition, a high NS score indicates that an individual takes risks and has a lack of behavioral inhibition and (without considering possible negative results) a strong tendency to engage in impulsive behavior (Pierò, 2010). Increased NS levels have been reported in patients with impulse control disorder, substance-use disorder, borderline personality disorder, and eating disorders ( Evren et al, 2007; Fassino et al., 2002; Fassino et al., 2009; Barnow et al., 2007). NS is directed by the dopamine neurotransmitter function in the central nervous system (Cloninger, 2000). There is evidence suggesting that the behavioral inhibition component of impulsiveness (motor impulsiveness) is arranged by dopaminergic genes (Congdon and Canli, 2008). In patients with 12
ACCEPTED MANUSCRIPT high NS levels and with generalized anxiety disorder who have a tendency toward impulsive behavior, there may be a tendency to try a modification in dopamine pathways (Munafò et al., 2008). Piero (2010) demonstrated that NS was a predictor of strong personality for impulsiveness in patients with generalized anxiety disorder and that NS results in patients are related to the attention, motor, and nonplanning components of the BIS (Pierò, 2010). Similarly, the relationship between hyperthymic and cyclothymic temperament and impulsiveness may be associated with an
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increase in NS activity. HA reflects the efficacy of the behavioral inhibition system and is related to serotonergic activity (Cloninger et al., 1993; Cloninger, 2000). Patients with high HA scores have pessimistic thoughts about the future, are avoidant, shy, and afraid of uncertainty, and they get tired easily (Cloninger et al., 1993). In these patients, an anxious personality, depressive disorders and comorbid anxiety
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and mood disorders may be observed (Cloninger, 1987; Ampollini et al., 1997). HA level is generally significant in generalized anxiety disorder (Cloninger, 2000). Higher HA scores have been demonstrated in the patient group when compared to the control group in many studies investigating the relationship between panic disorder and temperament (Ampollini et al., 1997; Ampollini et al., 1999; Saviotti et al., 1991; Battaglia et al., 1998; Kennedy et al., 2001; Wiborg et
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al., 2005). In a study carried out on morphine addicts, a significant and strong relationship has been demonstrated between HA and impulsiveness (Abassi and Abolghasemi, 2015). The
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relationship between cyclothymic temperament and impulsiveness in our study may be due to temperament being associated with high HA.
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In a study performed by Del Carlo et al (2013) on patients with PD, patients with comorbid cyclothymia had statistically significant higher cyclothymic temperament scores on the TEMPS-A
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compared to those without comorbid cyclothymia, and patients with comorbid cyclothymia had higher BIS total and motor impulsiveness scores compared to those without comorbid cyclothymia
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(Del Carlo et al., 2013). Similarly, Perugi et al. (2011) demonstrated that anxiety disorder patients with comorbid cyclothymia had higher depressive, cyclothymic, anxious, and irritable temperament scores on the TEMPS-A compared to those without cyclothymia, and patients with comorbid cyclothymia had higher BIS total, attention, and motor impulsiveness scores compared to those without cyclothymia; in addition, they suggested that impulsiveness might be associated with comorbid cyclothymia other than anxiety disorder directly (Perugi et al., 2011).
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ACCEPTED MANUSCRIPT To the best of my knowledge, this study is the first to investigate the correlation between affective temperament and impulsiveness in patients with PD. In the previous studies conducted, impulsiveness and temperament traits were investigated, however, there is no detailed research in publications with regard to the relationship of affective temperament with impulsiveness. Nevertheless, there are some limitations of this study, such as the small sample size, and the evaluation of patients in a second-step outpatient clinic that may prevent generalization of the
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findings. In conclusion, the results of this study indicate a relationship between impulsivity and PD. The findings that patients with PD have higher scores in some affective temperament and impulsiveness subscales than the controls and the correlations found between impulsivity dimensions and PD may support this relationship. In addition, the correlations found between
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affective temperament dimensions and impulsivity may demonstrate how affective temperamental traits may influence different impulsivity dimensions and may be possible risk factors for the appearance of impulsive acts. Further studies will be required to obtain information regarding this
Acknowledgements: None
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Conflict of interest: None to declare
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issue.
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ACCEPTED MANUSCRIPT Del Carlo, A., Benvenuti, M., Fornaro, M., Toni, C., Rizzato, S., Swann, A.C., et al., 2012. Different measures of impulsivity in patients with anxiety disorders: a case control study. Psychiatry Res. 197, 231-236. Del Carlo, A., Benvenuti, M., Toni, C., Dell'osso, L., Perugi, G., 2013. Impulsivity in patients with panic disorder-agoraphobia: the role of cyclothymia. Compr. Psychiatry. 54, 10901097. Dell'Osso, B., Altamura, A.C., Allen, A., Marazziti, D., Hollander, E., 2006. Epidemiologic and
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Pavlov, K.A., Chistiakov, D.A., Chekhonin, V.P., 2012. Genetic determinants of aggression and impulsivity in humans. J. Appl. Genet. 53, 61-82.
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Perugi, G., Del Carlo, A., Benvenuti, M., Fornaro, M., Toni, C., Akiskal, K., et al., 2011. Impulsivity in anxiety disorder patients: is it related to comorbid cyclothymia? J. Affect. Disord.133, 600-606. Pierò, A., 2010. Personality correlates of impulsivity in subjects with generalized anxiety disorders. Compr. Psychiatry. 51, 538-545. 18
ACCEPTED MANUSCRIPT Pilowsky, D.J., Wu, L.T., Anthony, J.C., 1999. Panic attacks and suicide attempts in midadolescence. Am. J. Psychiatry. 156, 1545-1549. Preve, M., Mula, M., Maltini, E., Pini, S., 2014. Panic-agoraphobic Spectrum Symptoms are Associated with Impulsivity in Bipolar Disorder. Ann. Depress. Anx. 1, 1016. Saviotti, F.M., Grandi, S., Savron, G., Ermentini, R., Bartolucci, G., Conti, S., et al., 1991. Characterological traits of recovered patients with panic disorder and agoraphobia. J. Affect. Disord. 23, 113-117.
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Summerfeldt, L., Hood, K., Antony, M.M., Richter, M.A., Swinson, R.P., 2004. Impulsivity in obsessive-compulsive disorder: comparisons with other anxiety disorders and within ticrelated subgroups. Pers. Individ. Dif. 36, 539-553.
Tatlidil Yaylaci, E., Kesebir, S., Güngördü, Ö., 2014. The relationship between impulsivity and lipid levels in bipolar patients: does temperament explain it? Compr. Psychiatry. 55, 883-
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886.
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Tomassini, A., Struglia, F., Stratta, P., Riccardi, I., Tempesta, D., Pacifico, R., et al., 2009.
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Affective temperaments and residual symptoms in patients with mood and anxiety disorders. Int. J. Psychiatry Clin. Pract. 13, 31-35.
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TEMPS-A. J. Affect. Disord. 85, 113-125. Vasconcelos, A.G., Malloy-Diniz, L., Correa, H., 2012. Systematic review of psychometric
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proprieties of Barratt Impulsiveness Scale Version 11 (BIS-11). Clinical Neuropsychiatry. 9, 61-74.
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Vickers, K., McNally, R.J., 2004. Panic disorder and suicide attempt in the National Comorbidity Survey. J. Abnorm. Psychol. 113, 582-591.
Wachleski, C., Salum, G.A., Blaya, C., Kipper, L., Paludo, A., Salgado, A.P., et al., 2008. Harm avoidance and self-directedness as essential features of panic disorder patients. Compr. Psychiatry. 49, 476-481. Walsh, M.A., Royal, A.M., Barrantes-Vidal, N., Kwapil, T.R., 2012. The association of affective temperaments with impairment and psychopathology in a young adult sample. J. Affect. Disord. 141, 373-381.
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ACCEPTED MANUSCRIPT Weissman, M.M., Klerman, G.L., Markowitz, J.S., Ouellette, R., 1989. Suicidal ideation and suicide attempts in panic disorder and attacks. N. Engl. J. Med. 321, 1209-1214. Wiborg, I.M., Falkum, E., Dahl, A.A., Gullberg, C., 2005. Is harm avoidance an essential feature of patients with panic disorder? Compr. Psychiatry. 46, 311-314.
30.4±10.4 43 (61.4%)
30.5±7.0 32 (55.2%)
20 (28.6%) 25 (35.7%) 25 (35.7%)
13 (22.4%) 24 (41.4%) 21 (36.2%)
16 (22.9%) 36 (51.4%) 18 (25.7%)
12 (20.7%) 29 (50%) 17 (29.3%)
32 (45.7%) 36 (51.4%) 2 (2.9%)
25 (43.1%) 32 (55.2%) 1 (1.7%)
1837.5a 0.512b 0.735b
p
0.356 0.474 0.693
0.231b
0.891
0.402c
0.941
1.332c
0.527
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7 (10%) 53 (75.7%) 10 (14.3%)
Test statistic
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Controls (n=58)
3 (5.2%) 44 (75.9%) 11(19%)
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Age, average (S.D.) Female gender, n (%) Education, n (%) ≤8 years High school University or > Occupation, n (%) Student Employed Unemployed/retired Marital status, n (%) Married/cohabiting Unmarried Widowed/divorced Income status, n (%) Low Middle High
Patients (n=70)
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Table 1. Sociodemographic features of PD patients and healthy controls
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a: Mann-Whitney U-test, b: Chi-square test, c:Fisher-exact test
Table 2. Clinical scale scores of PD patients and healthy controls Patients
Controls
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TEMPS-A depressive
8.0+3.6
4.2+2.7
<0.001
TEMPS-A cyclothymic
11.2+4.3
3.9+3.8
<0.001
TEMPS-A hyperthymic
10+4.6
9.6+4.6
0.728
TEMPS-A irritable
6.3+3.9
2.2+2.7
<0.001
TEMPS-A anxious
10.9+6.1
3.2+3.7
<0.001
Barratt Impulsiveness Scale (BIS) Attentional
16.9+3.1
15.4+2.6
Motor
20.9+3.4
20.1+3.3
Nonplanning
26.7+5.0
27.9+3.9
Total
64.8+7.4
63.4+6.8
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( n=70) Mean+SD
0.0031 0.143 0.182 0.245
TEMPS-A:Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire, BIS: Barratt Impulsiveness Scale
Student’s t test, others were performed with Mann-Whitney U test
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BIS-motor
BISnonplanning
BIS-total
-0.148; 0.223 -0.085; 0.484 -0.066; 0.590 0.156; 0.199 0.214; 0.075 0.294; 0.013 0.315; 0.008 0.196; 0.103 0.032; 0.792 0.097; 0.425 0.306; 0.010 0.145; 0.230 0.192; 0.112 0.103; 0.396 0.290; 0.015
0.010; 0.933 -0.034; 0.782 -0.069; 0.571 -0.153; 0.205 -0.189; 0.117 -0.140; 0.247 -0.080; 0.508 -0.248; 0.039 -0.220; 0.067 0.049; 0.684 -0.049; 0.686 0.078; 0.523 -0.139;0.252 0.224; 0.062 -0.125;0.303
-0.250; 0.037 -0.152; 0.208 0.020; 0.868 0.075; 0.538 0.136; 0.262 -0.182; 0.132 0.069; 0.569 0.063; 0.604 -0.003; 0.978 -0.180; 0.136 -0.215; 0.073 -0.273; 0.022 -0.139; 0.252 -0.010; 0.932 -0.151; 0.211
-0.186; 0.123 -0.112; 0.356 -0.082; 0.501 0.039; 0.750 0.064; 0.598 -0.055; 0.651 0.180; 0.135 0.040; 0.744 -0.039; 0.751 -0.075; 0.536 -0.055; 0.651 -0.086; 0.477 -0.078; 0.522 0.109; 0.367 -0.029; 0.812
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BIS-attentional
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PAS A1 PAS A2 PAS A3 PAS U PAS B1 PAS B2 PAS B3 PAS C1 PAS C2 PAS D1 PAS D2 PAS D3 PAS E1 PAS E2 PAS Total
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Table 3. Correlations between impulsivity dimensions and PAS items
PAS: Panic and Agoraphobia Scale, BIS: Barratt Impulsiveness Scale
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Table 4. Correlations between TEMPS-A scale sores and Impulsivity dimensions in the patient group BIS-attentional
BIS-motor
BISnonplanning
BIS-total
Depressive Cyclothymic Hyperthymic Irritable Anxious
0.174; 0.050 0.345; <0.001 0.147; 0.098 0.304; <0.001 0.319; <0.001
0.132; 0.139 0.291; 0.001 0.232; 0.009 0.208; 0.018 0.119; 0.182
-0.019; 0.830 -0.184; 0.037 0.204; 0.021 -0.093; 0.298 -0.115; 0.196
0.147; 0.099 0.221; 0.012 0.304; <0.001 0.220; 0.013 0.150; 0.090
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r;p* TEMPS-A
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BIS: Barratt Impulsiveness Scale, TEMPS-A:Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire *Spearman’s Rho Correlation Coefficient
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The relationship between impulsivity and panic disorder-agoraphobia: the role of affective temperament Aslı Bes¸irli PII: DOI: Reference:
S0165-1781(17)31543-3 10.1016/j.psychres.2018.03.021 PSY 11253
To appear in:
Psychiatry Research
Received date: Revised date: Accepted date:
19 August 2017 27 December 2017 7 March 2018
Please cite this article as: Aslı Bes¸irli , The relationship between impulsivity and panic disorder-agoraphobia: the role of affective temperament, Psychiatry Research (2018), doi: 10.1016/j.psychres.2018.03.021
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Highlights: There is a relationship between impulsivity and panic disorder. There are correlations between affective temperament dimensions and impulsivity
Affective temperamental traits influence impulsivity.
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Aslı Beşirlia*
: Department of Psychiatry, University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, Şişli, İstanbul,Turkey
*Corresponding Author: Aslı Beşirli, MD
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THE RELATIONSHIP BETWEEN IMPULSIVITY AND PANIC DISORDERAGORAPHOBIA: THE ROLE OF AFFECTIVE TEMPERAMENT
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Department of Psychiatry, University of Health Sciences, Şişli Hamidiye Etfal Training and
Phone: (+90) 212 3735000
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Fax : (+90) 212 2240772
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Research Hospital, Halaskargazi Street, 34371- Şişli, İstanbul, Turkey
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E-mail: [email protected]
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ABSTRACT
There are opinions regarding that impulsivity may play a role in the pathogenesis of neuropsychiatric disorders. The aim of this study was to investigate the relationship between impulsivity and panic disorder (PD) in the patient group, to compare impulsivity and affective temperamental traits between patients and healthy controls and to investigate whether there is a relationship between impulsivity and affective temperamental traits. Participants comprised 70 patients with PD and 58 healthy volunteers. The panic agoraphobia scale (PAS), the Barratt impulsiveness scale (BIS-11) and the Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire (TEMPS-A) were applied. Patients have significantly higher scores in 2
ACCEPTED MANUSCRIPT affective temperament (except hyperthymic) and attentional impulsiveness subscales than the healthy controls. Positive and negative correlations were found between some PAS and BIS-11 scores as well as correlations between especially cyclothymic, hyperthymic, irritable and anxious subscale scores of the TEMPS-A and the BIS-11 scores in the patient group. The results of this study indicate a relationship between impulsivity and PD. The correlations found between affective temperament dimensions and impulsivity suggest how affective temperamental traits
Key Words: Panic disorder; impulsiveness; temperamental traits.
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1. Introduction
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may influence different impulsivity dimensions.
Impulsivity is a trait of both normal and pathological behavior, characterizing a transition from tendency to taking action. It is also a determinant of personal differences, psychiatric disorders, and related risk-taking behaviors (Chamorro et al., 2012; Dell'Osso et al., 2006). Some researchers
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believe that impulsivity may play a role in the pathogenesis of neuropsychiatric disorders. Impulsivity has been investigated in the study of many mental disorders, such as affective
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disorders, personality disorders, alcohol addiction, attention deficit hyperactivity disorder, and bulimia nervosa (Jakuszkowiak-Wojten et al., 2015a). According to Eysenck’s definition,
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extroverted impulsivity demonstrates a decision process that takes into account the results and risks of an action, whereas impulsivity of a psychotic degree does not consider risks (Eysenck et
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al., 1985).
The association between anxiety and impulsiveness is controversial, but it is conventionally
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considered that impulsiveness is inversely related to anxiety (Barratt, 1965; Askenazy et al., 2000). Some studies found no association between anxiety and impulsiveness (Askenazy et al., 2000; Apter et al., 1993; Lecrubier et al., 1995). However, there is large amount of data setting forth the comorbidity of anxiety disorders and impulse control disorders, or impulsivity (Preve et al., 2014; Del Carlo et al., 2013; Summerfeldt et al., 2004). In addition, individuals with impulse control disorder feel more anxiety and tension before their impulsive actions (Preve et al., 2014). However, it has been suggested that anxiety could be a protective factor against uninhibited,
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ACCEPTED MANUSCRIPT potentially dangerous behaviors and may be protective against impulsivity as well (Taylor et al., 2008). Askenazi et al. (2003) evaluated the level of anxiety and impulsivity in adolescents hospitalized for a number of behavioral problems (suicide attempts, aggressive behavior, substance poisoning, faulty behavior, and eating disorders). In this study, it has been stated that the comorbidity of anxiety and impulsivity with mood disorders is a strong risk predictor with regard to suicide
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attempts. In addition, the presence of anxiety in impulsive persons may lead to introverted aggressiveness instead of preventing behavioral dyscontrol. Impulsivity without anxiety has been found to be associated with antisocial behaviors, behavioral disorders, and aggressive behaviors directed toward others (Askénazy et al., 2003).
In many studies, it has been shown that bipolar patients with comorbid anxiety disorder are more
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impulsive compared to those without comorbid anxiety disorder (Del Carlo et al., 2013). Even though harm avoidance and behavioral inhibition are observed in anxiety disorders (Taylor et al., 2008), it has been suggested that patients with anxiety are more impulsive compared to healthy controls (Del Carlo et al., 2013).
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Epidemiological data indicate that panic disorder (PD) is one of the anxiety disorders that disrupts functionality the most (Nutt, 2011). The relationship between panic disorder and impulsivity has
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not been sufficiently investigated (Del Carlo et al., 2013). Although the presence of aggressive behavior has been shown in patients with PD in many studies (Korn et al., 1997; Pilowsky et al., 1999; Beck et al., 1991; Vickers and McNally, 2004), the relationship between PD and aggression
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has not been fully explained.
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Anxiety and impulsivity are two main risk factors for suicide (Pierò, 2010). Data regarding behaviors that are strongly related to impulsivity, such as unpremeditated suicide and aggression,
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have been reported in a small number of studies (Neufeld and O'Rourke, 2009; Pavlov et al., 2012; Gvion and Apter, 2011). In some studies of patients with PD, the ideation and attempt of murder have been reported to be higher (Korn et al., 1997; Weissman et al., 1989); whereas in some studies, it has been demonstrated that lifelong PD is not associated with increased suicide attempts and patients with PD that have a higher risk regarding suicide attempts have been shown to have other comorbid disorders (Vickers and McNally, 2004). In one study, it was reported that 31.7% of patients with PD had suicidal ideation during the last two weeks and that severity of panic symptoms, weak social support, youth, and alcohol use were 4
ACCEPTED MANUSCRIPT associated with suicidal ideation (Huang et al., 2010). However, although it is known that patients with PD have aggressive behavior (Korn et al., 1997; George et al., 1989), the relationship between PD and aggression has not been fully explained. Conventionally, temperament that emerges at an early age, and is partially affected by genetic structure, indicates stable behavior and emotional reactions (Tomassini et al., 2009). In the psychobiological model set forth by Cloninger et al. (1993), personality is divided into two halves,
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temperament and character. The most commonly used questionnaires in this model are the Tridimensional Personality Questionnaire (TPQ) and the Temperament and Character Inventory (TCI). In the TCI, 4 dimensions of temperament—novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence (P)—and 3 dimensions of character)—self-directedness (SD), cooperativeness (C), and self-transcendence)—have been defined (Cloninger et al., 1993).
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Akiskal et al. (2005) made a new arrangement by adding anxious temperament to the four types of temperament (depressive, hyperthymic, irritable, and cyclothymic) set forth by Kraepelin. To be able to examine temperament better, Akiskal developed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A) questionnaire for research and clinical purposes. The questionnaire, composed of 110 items, has been translated into more than 25 languages, and
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validity studies of most of them have been performed (Akiskal et al., 2005). In TEMPS-A, depressive and cyclothymic dimensions were associated with high HA, whereas hyperthymic and
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cyclothymic dimensions were associated with high NS (Maremmani et al., 2005). Even though there are many publications on temperament and mood disorders, there have been
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only a few systematic studies done regarding the relationship of anxiety disorder and temperament. In one of these publications, Tomassini et al. (2009) found that there was no
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significant difference regarding brief TEMPS-M scores between the two groups in their study that compared 45 patients with anxiety disorders and 56 patients with mood disorders (Tomassini et
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al., 2009).
Adult patients with PD have character profiles and temperaments showing a higher HA and lower SD as also defined by Cloninger (Wachleski et al., 2008; Perna et al., 1994), and it has been reported in cross-sectional studies that there is a relationship between anxiety symptoms or anxiety disorders and HA ( Brown et al., 1992; Jylhä and Isometsä, 2006). In the light of all these data, the aim of this study is to investigate the relationship between impulsivity and PD in the patient group, to compare impulsivity and affective temperamental traits 5
ACCEPTED MANUSCRIPT between patients with PD and healthy controls and to investigate whether there is a relationship between impulsivity and affective temperamental traits in patients with PD. My hypothesis has proposed that the relationship between impulsivity and PD might be affected by affective
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temperamental traits.
2. Methods
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2.1. Subjects
Seventy patients between the ages of 18 and 65 who were psychotropic drug-naive and presented
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to the psychiatry outpatient clinic, where they were diagnosed for the first time with PD with or without agoraphobia according to the DSM-5 (American Psychiatric Association, 2013) criteria.
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To form the control group, 58 healthy volunteers matching the patient group with regard to age, gender, education, occupation, marital status, and income were included in the study. Patients who
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were younger than 18 and older than 65 years of age; or were illiterate; still in a depressive, manic, or hypomanic episode; using illicit drugs, antidepressants, or dibenzodiazepines, etc.; who had
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cyclothymic disorder, dysthymic disorder, schizophrenia or other psychotic disorders, alcohol and substance use disorders, mental retardation, other somatic comorbidity, or any other conditions apart from anxiety disorder, such as neurological disease, serious heart, circulation, endocrine, or respiratory disease; or who did not agree to participate in the study were not included in the study. No urine drug test was performed. Patients’ self-reports were taken into consideration. Any other treatments such as psychotherapy or other concomitant treatment were not administered. The same criteria were considered as exclusion criteria for the healthy volunteers in the control group.
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ACCEPTED MANUSCRIPT The trial protocol was approved by the local ethics committee. Written informed consent was obtained from the patients after the purposes and course of conduct of the trial being planned was conveyed to the patients. 2.2. Procedures To determine the severity of the panic disorder, the panic agoraphobia scale (PAS) was applied. The PAS scale identifies 13 items grouped into 5 subscales: 1. panic attacks (frequency, severity,
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and duration), 2. agoraphobia (frequency, number, and relevance of situations), 3. anticipatory anxiety (frequency and severity), 4. disability (family, social relationships, and employment), and 5. worries about health (worries about health damage due to panic attacks and assumption of organic disease). Every subscore consists of its component scores, and the total score is obtained
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by summing up all subscores ( Bandelow et al., 1998).
Impulsivity was evaluated with the Barratt impulsiveness scale (BIS-11). The BIS-11 was used to assess three impulsiveness dimensions: attentional, motor, and nonplanning. The total score was determined by summing all items. The higher the score, the higher is the level of impulsivity (Summerfeldt et al., 2004; Patton et al., 1995; Vasconcelos et al., 2012).
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The Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire (TEMPS-A) questionnaire was used to evaluate temperamental traits. The TEMPS-A consists of 100
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dichotomous items assessing 5 temperament dimensions: depressive, cyclothymic, hyperthymic, et al. (2005).
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irritable, and anxious temperaments (Akiskal et al., 2005). It was translated into Turkish by Vahip
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2.3.Statistical analysis
Descriptive statistics were used to define continuous variables (mean, standard deviation, minimum, median, maximum). The comparison of independent and normally distributed two
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continuous variables was performed with Student’s t-test, and the comparison of the independent and nonnormal two variables was performed with the Mann-Whitney U Test. Chi-square (or where appropriate the Fisher Exact Test) was used to examine the relationship between categorical variables. Correlation between the continuous nonnormal variables was examined with Spearman’s correlation coefficient. The level of statistical significance was determined at 0.05. Analyses were performed using MedCalc Statistical Software version 12.7.7 (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2013).
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3. Results
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3.1. Sociodemographic characteristics of the patients and control groups There were no statistically significant differences between the patients and control groups with
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regards to age, gender, educational status, marital status, occupation, and income. The number of patients who were diagnosed with PD and comorbid agoraphobia was 60 (85.7%), and the number
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of patients diagnosed with PD only was 10 (14.3%) in the entire patient group (n = 70) (Table 1).
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3.2. Clinical scale scores of PD patients and healthy controls The depressive, cyclothymic, irritable, and anxious scores of the TEMPS-A and the attentional
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impulsiveness subscale scores of BIS-11 were statistically higher in the patient group than in the control group. The hyperthymic score of the TEMPS-A and the motor, nonplanning, and total impulsiveness subscale scores of the BIS-11 did not reveal a statistically significant difference between patients and the control group (Table 2). 3.3. Relationship between impulsivity dimensions and PAS items A negative and statistically significant correlation between PAS A1 (panic attacks, severity) and the BIS nonplanning subscale score (r =- 0.250, p = 0.037), a weak and statistically significant 8
ACCEPTED MANUSCRIPT correlation between PAS B2 (agoraphobia, number of situations) and the BIS attentional subscale score (r = 0.294, p = 0.013), a weak and statistically significant correlation between PAS B3 (agoraphobia, relevance of situations) and the BIS attentional subscale score (r = 0.315, p = 0.008), a weak, negative, and statistically significant correlation between PAS C1 (anticipatory anxiety, frequency) and the BIS motor subscale score (r = -0.248, p = 0.039), and a weak, negative, and statistically significant correlation between PAS D3 (disability; employment, housework) and the BIS nonplanning subscale score (r = -0.273, p = 0.022) were also found.
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There was no statistically significant correlation between the other scales (Table 3).
3.4. Relationship between the TEMPS-A scale sores and impulsivity dimensions in the patient group
There was a weak and statistically significant correlation between the cyclothymic score of the
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TEMPS-A and the attentional, motor, and total impulsiveness scores of the BIS-11 (r = 0.345, p<0.001; r = 0.291, p = 0.001; r = 0.221, p = 0.012, respectively), and there was a weak,
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negative, and statistically significant correlation between the cyclothymic score of the TEMPS-A
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and the nonplanning subscale score of the BIS-11 (r = -0.184, p = 0.037). A weak and statistically significant correlation between the hyperthymic score of the TEMPS-A
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and the motor, nonplanning, and total impulsiveness scores of the BIS (r = 0.232, p = 0.009; r = 0.204, p = 0.021; r = 0.304, p<0.001, respectively), a weak and statistically significant correlation
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between the irritable score of the TEMPS-A and the attentional, motor, and total impulsiveness scores of the BIS (r = 0.304, p <0.001; r = 0.208, p = 0.018; r = 0.220, p = 0.013, respectively), a weak and statistically significant correlation between the anxious score of the TEMPS-A and the attentional subscale score of the BIS. (r = 0.319, p < 0.001) were also found. No statistically significant correlation was found between the depressive score of the TEMPS-A and the BIS total and subscores (Table 4).
9
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4. Discussion
4.1. Symptomatological and Temperamental Assessment
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In this study, the depressive, cyclothymic, irritable, and anxious scores of the TEMPS-A were statistically significantly higher in the patient group when compared to the control group, whereas
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the hyperthymic score of the TEMPS-A did not show a statistically significant difference between the patient and control groups. The findings of this study are consistent with the findings of prior
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studies (Del Carlo et al., 2012; Perugi et al., 2011; Altınbaş et al., 2015).
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4.2. Assessment of Impulsiveness In this study, the attentional impulsiveness score of the BIS in the patient group was statistically
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higher as compared to the control group. Motor, nonplanning, and total BIS scores did not reveal a statistically significant difference between patients and the control group. Distinct from this study, Del Carlo et al. (2012) found that BIS total and all BIS subscores in patients with anxiety disorder were higher than in the control group (Del Carlo et al., 2012). In another study, it has been demonstrated that, similarly, the BIS total and all BIS subscores of PD patients were higher as compared to the control group (Del Carlo et al., 2013). Again in another study, the BIS total and attention and nonplanning scores of all patients in the anxiety disorder group have been reported to be higher as compared to the control group (Summerfeldt et al., 2004). Perugi et al. (2011), 10
ACCEPTED MANUSCRIPT found that in patients with various anxiety disorders (PD, obsessive compulsive disorder, social phobia, generalized anxiety disorder), the BIS total, attention, and motor scores were higher than the control group, and there was no statistically significant difference between the patient and control groups with regard to nonplanning scores (Perugi et al., 2011). 4.3. Assessment of the Relationship Between Panic Disorder and Impulsivity in the Patient Group
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The findings in literature investigating the relationship between PD and impulsiveness are inconsistent. In this study, both positive and negative correlations were found between some PAS and BIS subscores. In some studies, a positive correlation has been reported between anxiety disorder and impulsiveness (Del Carlo et al., 2013; Summerfeldt et al., 2004; Kashdan et al., 2008). In one study, the BIS was used on a group of patients with anxiety disorder (40 obsessive
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compulsive disorder, 37 PD, and 24 social anxiety disorder patients), and both total and attentional impulsiveness and nonplanning subscores were reported to be higher in the patient group than in the control group ( Summerfeldt et al., 2004). In another study, composed of 47 patients with different anxiety disorders (panic disorder, obsessive compulsive disorder, social phobia, generalized anxiety disorder), the BIS total score and all subscores thereof were significantly
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higher than those of the control group (Del Carlo et al., 2012).
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Correlation between the severity of PD and impulsiveness has been investigated in a few studies. In a study carried out by Jakuszkowiak-Wojten et al. (2015), the correlation between the PAS scores and the BIS-11 scores of 21 drug-free PD patients were investigated, and the results
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demonstrated a correlation between the attentional impulsiveness of BIS and PAS D3 (disability, employment, housework) and nonplanning of BIS and PAS E1 (worries about health damage)
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(Jakuszkowiak-Wojten et al., 2015b). In another study, researchers found that the BIS scores of patients with PD were higher than those of the control group, and there was a correlation between
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impulsiveness and cognitive functions (Jakuszkowiak-Wojten et al., 2013).
4.4. Assessment of the Relationship Between Impulsiveness and Temperament Scores in the Patient Group There was a weak and statistically significant correlation between the cyclothymic temperament score and the attentional, motor, and total impulsiveness scores of the BIS, and there was a weak, negative, and statistically significant correlation between the cyclothymic temperament score and 11
ACCEPTED MANUSCRIPT the nonplanning subscore of the BIS. In addition, a weak and statistically significant correlation was determined between the irritable temperament score and the attentional, motor, and total impulsiveness scores of the BIS in this study. A strong relationship between impulsiveness and cyclothymic and irritable temperament was also determined in a study they performed in patients with bipolar disorder (Tatlidil Yaylaci et al., 2014). A weak and statistically significant correlation between the anxious temperament score and the
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attentional impulsiveness score of the BIS has been found in this study. Also, there was a weak and statistically significant correlation between the hyperthymic score and the motor, nonplanning, and total impulsiveness score of the BIS. In their study, Tatlıdil Yaylacı et al. (2014) demonstrated that there was a moderate relationship between impulsiveness and an anxious temperament; however, distinct from this study, that there was no correlation between the
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hyperthymic temperament and impulsiveness. In addition, no relationship between depressive temperament scores and impulsiveness has been found in this study, whereas Tatlıdil Yaylacı et al. (2014) showed that there was a moderate relationship between depressive temperament and impulsiveness (Tatlidil Yaylaci et al., 2014). Similar to the findings of this study, Walsh et al. (2012) showed that impulsiveness was associated with cyclothymic, hyperthymic, and irritable
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temperaments (Walsh et al., 2012). It is suggested that the strong relationship between impulsiveness and cyclothymic and irritable temperaments was mainly related to irritability. In
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addition, the relationship between impulsiveness and anxious and depressive temperaments might
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be related to the feeling of subjective stress and anxiety (Tatlidil Yaylaci et al., 2014). In the TEMPS-A, depressive and cyclothymic dimensions were associated with high HA, whereas
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hyperthymic and cyclothymic dimensions were associated with high NS (Maremmani et al., 2005). NS signifies the activation level of exploratory activities. Persons with high NS scores perform
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exploratory activities more and have a tendency toward rapid decision-making and extravagance. In addition, a high NS score indicates that an individual takes risks and has a lack of behavioral inhibition and (without considering possible negative results) a strong tendency to engage in impulsive behavior (Pierò, 2010). Increased NS levels have been reported in patients with impulse control disorder, substance-use disorder, borderline personality disorder, and eating disorders ( Evren et al, 2007; Fassino et al., 2002; Fassino et al., 2009; Barnow et al., 2007). NS is directed by the dopamine neurotransmitter function in the central nervous system (Cloninger, 2000). There is evidence suggesting that the behavioral inhibition component of impulsiveness (motor impulsiveness) is arranged by dopaminergic genes (Congdon and Canli, 2008). In patients with 12
ACCEPTED MANUSCRIPT high NS levels and with generalized anxiety disorder who have a tendency toward impulsive behavior, there may be a tendency to try a modification in dopamine pathways (Munafò et al., 2008). Piero (2010) demonstrated that NS was a predictor of strong personality for impulsiveness in patients with generalized anxiety disorder and that NS results in patients are related to the attention, motor, and nonplanning components of the BIS (Pierò, 2010). Similarly, the relationship between hyperthymic and cyclothymic temperament and impulsiveness may be associated with an
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increase in NS activity. HA reflects the efficacy of the behavioral inhibition system and is related to serotonergic activity (Cloninger et al., 1993; Cloninger, 2000). Patients with high HA scores have pessimistic thoughts about the future, are avoidant, shy, and afraid of uncertainty, and they get tired easily (Cloninger et al., 1993). In these patients, an anxious personality, depressive disorders and comorbid anxiety
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and mood disorders may be observed (Cloninger, 1987; Ampollini et al., 1997). HA level is generally significant in generalized anxiety disorder (Cloninger, 2000). Higher HA scores have been demonstrated in the patient group when compared to the control group in many studies investigating the relationship between panic disorder and temperament (Ampollini et al., 1997; Ampollini et al., 1999; Saviotti et al., 1991; Battaglia et al., 1998; Kennedy et al., 2001; Wiborg et
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al., 2005). In a study carried out on morphine addicts, a significant and strong relationship has been demonstrated between HA and impulsiveness (Abassi and Abolghasemi, 2015). The
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relationship between cyclothymic temperament and impulsiveness in our study may be due to temperament being associated with high HA.
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In a study performed by Del Carlo et al (2013) on patients with PD, patients with comorbid cyclothymia had statistically significant higher cyclothymic temperament scores on the TEMPS-A
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compared to those without comorbid cyclothymia, and patients with comorbid cyclothymia had higher BIS total and motor impulsiveness scores compared to those without comorbid cyclothymia
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(Del Carlo et al., 2013). Similarly, Perugi et al. (2011) demonstrated that anxiety disorder patients with comorbid cyclothymia had higher depressive, cyclothymic, anxious, and irritable temperament scores on the TEMPS-A compared to those without cyclothymia, and patients with comorbid cyclothymia had higher BIS total, attention, and motor impulsiveness scores compared to those without cyclothymia; in addition, they suggested that impulsiveness might be associated with comorbid cyclothymia other than anxiety disorder directly (Perugi et al., 2011).
13
ACCEPTED MANUSCRIPT To the best of my knowledge, this study is the first to investigate the correlation between affective temperament and impulsiveness in patients with PD. In the previous studies conducted, impulsiveness and temperament traits were investigated, however, there is no detailed research in publications with regard to the relationship of affective temperament with impulsiveness. Nevertheless, there are some limitations of this study, such as the small sample size, and the evaluation of patients in a second-step outpatient clinic that may prevent generalization of the
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findings. In conclusion, the results of this study indicate a relationship between impulsivity and PD. The findings that patients with PD have higher scores in some affective temperament and impulsiveness subscales than the controls and the correlations found between impulsivity dimensions and PD may support this relationship. In addition, the correlations found between
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affective temperament dimensions and impulsivity may demonstrate how affective temperamental traits may influence different impulsivity dimensions and may be possible risk factors for the appearance of impulsive acts. Further studies will be required to obtain information regarding this
Acknowledgements: None
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Conflict of interest: None to declare
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issue.
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ACCEPTED MANUSCRIPT Weissman, M.M., Klerman, G.L., Markowitz, J.S., Ouellette, R., 1989. Suicidal ideation and suicide attempts in panic disorder and attacks. N. Engl. J. Med. 321, 1209-1214. Wiborg, I.M., Falkum, E., Dahl, A.A., Gullberg, C., 2005. Is harm avoidance an essential feature of patients with panic disorder? Compr. Psychiatry. 46, 311-314.
30.4±10.4 43 (61.4%)
30.5±7.0 32 (55.2%)
20 (28.6%) 25 (35.7%) 25 (35.7%)
13 (22.4%) 24 (41.4%) 21 (36.2%)
16 (22.9%) 36 (51.4%) 18 (25.7%)
12 (20.7%) 29 (50%) 17 (29.3%)
32 (45.7%) 36 (51.4%) 2 (2.9%)
25 (43.1%) 32 (55.2%) 1 (1.7%)
1837.5a 0.512b 0.735b
p
0.356 0.474 0.693
0.231b
0.891
0.402c
0.941
1.332c
0.527
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7 (10%) 53 (75.7%) 10 (14.3%)
Test statistic
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Controls (n=58)
3 (5.2%) 44 (75.9%) 11(19%)
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Age, average (S.D.) Female gender, n (%) Education, n (%) ≤8 years High school University or > Occupation, n (%) Student Employed Unemployed/retired Marital status, n (%) Married/cohabiting Unmarried Widowed/divorced Income status, n (%) Low Middle High
Patients (n=70)
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Table 1. Sociodemographic features of PD patients and healthy controls
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a: Mann-Whitney U-test, b: Chi-square test, c:Fisher-exact test
Table 2. Clinical scale scores of PD patients and healthy controls Patients
Controls
20
p
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TEMPS-A depressive
8.0+3.6
4.2+2.7
<0.001
TEMPS-A cyclothymic
11.2+4.3
3.9+3.8
<0.001
TEMPS-A hyperthymic
10+4.6
9.6+4.6
0.728
TEMPS-A irritable
6.3+3.9
2.2+2.7
<0.001
TEMPS-A anxious
10.9+6.1
3.2+3.7
<0.001
Barratt Impulsiveness Scale (BIS) Attentional
16.9+3.1
15.4+2.6
Motor
20.9+3.4
20.1+3.3
Nonplanning
26.7+5.0
27.9+3.9
Total
64.8+7.4
63.4+6.8
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( n=70) Mean+SD
0.0031 0.143 0.182 0.245
TEMPS-A:Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire, BIS: Barratt Impulsiveness Scale
Student’s t test, others were performed with Mann-Whitney U test
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1
BIS-motor
BISnonplanning
BIS-total
-0.148; 0.223 -0.085; 0.484 -0.066; 0.590 0.156; 0.199 0.214; 0.075 0.294; 0.013 0.315; 0.008 0.196; 0.103 0.032; 0.792 0.097; 0.425 0.306; 0.010 0.145; 0.230 0.192; 0.112 0.103; 0.396 0.290; 0.015
0.010; 0.933 -0.034; 0.782 -0.069; 0.571 -0.153; 0.205 -0.189; 0.117 -0.140; 0.247 -0.080; 0.508 -0.248; 0.039 -0.220; 0.067 0.049; 0.684 -0.049; 0.686 0.078; 0.523 -0.139;0.252 0.224; 0.062 -0.125;0.303
-0.250; 0.037 -0.152; 0.208 0.020; 0.868 0.075; 0.538 0.136; 0.262 -0.182; 0.132 0.069; 0.569 0.063; 0.604 -0.003; 0.978 -0.180; 0.136 -0.215; 0.073 -0.273; 0.022 -0.139; 0.252 -0.010; 0.932 -0.151; 0.211
-0.186; 0.123 -0.112; 0.356 -0.082; 0.501 0.039; 0.750 0.064; 0.598 -0.055; 0.651 0.180; 0.135 0.040; 0.744 -0.039; 0.751 -0.075; 0.536 -0.055; 0.651 -0.086; 0.477 -0.078; 0.522 0.109; 0.367 -0.029; 0.812
PT
ED
BIS-attentional
CE
AC
PAS A1 PAS A2 PAS A3 PAS U PAS B1 PAS B2 PAS B3 PAS C1 PAS C2 PAS D1 PAS D2 PAS D3 PAS E1 PAS E2 PAS Total
M
Table 3. Correlations between impulsivity dimensions and PAS items
PAS: Panic and Agoraphobia Scale, BIS: Barratt Impulsiveness Scale
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ACCEPTED MANUSCRIPT
Table 4. Correlations between TEMPS-A scale sores and Impulsivity dimensions in the patient group BIS-attentional
BIS-motor
BISnonplanning
BIS-total
Depressive Cyclothymic Hyperthymic Irritable Anxious
0.174; 0.050 0.345; <0.001 0.147; 0.098 0.304; <0.001 0.319; <0.001
0.132; 0.139 0.291; 0.001 0.232; 0.009 0.208; 0.018 0.119; 0.182
-0.019; 0.830 -0.184; 0.037 0.204; 0.021 -0.093; 0.298 -0.115; 0.196
0.147; 0.099 0.221; 0.012 0.304; <0.001 0.220; 0.013 0.150; 0.090
CR IP T
r;p* TEMPS-A
AC
CE
PT
ED
M
AN US
BIS: Barratt Impulsiveness Scale, TEMPS-A:Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire *Spearman’s Rho Correlation Coefficient
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