You are on page 1of 6

Temperament and character dimensions in bipolar I disorder:

A comparison to healthy controls


Shay T. Loftus
*
, Jessica L. Garno, Judith Jaeger, Anil K. Malhotra
The Zucker Hillside Hospital, Department of Psychiatry Research, North Shore Long Island Jewish Health System,
75-59 263rd Street, Glen Oaks, NY 11004, United States
Received 29 January 2007; received in revised form 11 November 2007; accepted 15 November 2007
Abstract
Research on phenotypic markers of vulnerability to bipolar disorder has focused on the identication of personality traits uniquely
associated with the illness. To expand knowledge in this area, we compared Cloningers seven temperament and character dimensions in
85 euthymic/subsyndromal bipolar I inpatients and outpatients and 85 age and sex matched community controls. We also examined
associations between Cloningers personality traits and mood state in the patient group. Bipolar subjects were administered the Struc-
tured Clinical Interview for DSM-IV (SCID), Hamilton Rating Scale for Depression, and Clinician-Administered Rating Scale for
Mania. Controls received the SCID, a family psychiatric history questionnaire, and urine toxicology screen to conrm healthy status.
Both groups competed the 240-item Temperament and Character Inventory (TCI). A multivariate analysis of covariance, accounting
for demographic factors, was conducted to compare the groups on the TCI. Bipolar I patients scored higher on harm avoidance, lower
on self-directedness, and higher on self-transcendence compared to controls. Harm avoidance and self-directedness were correlated with
residual depressive symptoms positively and negatively, respectively; persistence was correlated with residual manic symptoms; and self-
transcendence was correlated with residual psychotic symptoms in patients. The results indicate that bipolar I subjects do possess per-
sonality traits that are signicantly dierent from non-ill individuals. However, only a prospective, longitudinal study may determine
whether these traits mark a vulnerability to the disorder, or represent the scarring eect of aective episodes and chronic subsyndromal
symptoms.
2007 Elsevier Ltd. All rights reserved.
Keywords: Bipolar disorder; Personality; Temperament; Character; State-trait
1. Objectives of the study
Investigators have identied personality traits that may
represent markers of bipolar illness (Engstrom et al.,
2004; Nowakowska et al., 2005; Solomon et al., 1996), mod-
ify its course (Lozano and Johnson, 2001; Swendsen et al.,
1995) or inuence treatment response (Maj et al., 1984).
The relationship of personality to aective disorders is com-
plex, however, since many traits appear to be unstable,
varying with changes in symptom levels (Hirshfeld et al.,
1983; Peselow et al., 1995). This phenomenon, known as
the state-trait eect, can result in the exaggeration of path-
ological personality traits during acute symptomatic peri-
ods as well as during periods of relative stability. Adding
to the complexity, multiple aective episodes may have a
scarring eect, leading chronically ill patients to report
exaggerated traits compared to those in the early stages of
illness (Hirschfeld et al., 1989; Dunayevich et al., 1996).
A widely used trait model in bipolar research currently is
Cloninger et al.s (1991, 1993, 1994) seven-factor biosocial
model of personality, comprised of four dimensions of tem-
perament and three dimensions of character. The tempera-
ment dimensions (novelty seeking, harm avoidance, reward
dependence, and persistence) are posited to be independent,
0022-3956/$ - see front matter 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpsychires.2007.11.005
*
Corresponding author.
E-mail address: loftus.shay@yahoo.com (S.T. Loftus).
JOURNAL OF
PSYCHIATRIC
RESEARCH
Available online at www.sciencedirect.com
Journal of Psychiatric Research 42 (2008) 11311136
www.elsevier.com/locate/jpsychires
biologically-based predispositions that are stable through-
out life. Novelty seeking reects a tendency to respond
actively to novel cues of reward or punishment. Harm
avoidance is a trait leading to behaviors that avoid aversive
stimuli. Reward dependence represents an inclination to
respond strongly to cues of social reward; and persistence
maintains previously established behaviors.
Cloninger et al.s (1993, 1994) character dimensions (self
directedness, cooperativeness, and self-transcendence), in
contrast, evolve throughout the lifespan, and are inuenced
by social and environmental factors. Self-directedness is the
ability to adapt ones behaviors to achieve chosen goals.
Cooperativeness is a tendency to empathize with, accept
and cooperate with others. Finally, self-transcendence cor-
responds to an identication or spiritual union with nature
or the universe.
Studies examining the temperament dimensions in bipo-
lar, unipolar, and healthy subjects using the Tridimensional
Personality Questionnaire (Cloninger, 1987) have yielded
inconsistent results. Young and colleagues (1995) found
recovered bipolar outpatients higher in novelty seeking
than both unipolar depressives and age-matched controls,
while both patient groups were higher in harm avoidance
than healthy subjects. Osher et al. (1996) reported that
euthymic outpatients scored lower in persistence and
higher in harm avoidance and reward dependence than
population norms. However, in a replication study (Osher
et al., 1999) comparing euthymic outpatients to sex, but not
age-matched controls, bipolar patients scored lower in nov-
elty seeking and persistence. The dierence in novelty seek-
ing in the latter study was explained by the higher mean age
of patients, as novelty seeking had been observed previ-
ously to decrease with age in a large probability sample
(Cloninger et al., 1991).
In a sample of rst-episode psychotic inpatients, Stra-
kowski et al. (1992) found that bipolar manic subjects
had lower harm avoidance scores than depressive, mixed,
and nonaective subjects. Further, a positive correlation
was observed between harm avoidance and depressive
symptoms; and a negative correlation, between harm
avoidance and manic symptoms, suggesting that harm
avoidance was vulnerable to state eects.
Engstrom and colleagues (2004) administered the Tem-
perament and Character Inventory (TCI; Cloninger et al.,
1993, 1994) to euthymic bipolar I and II outpatients and
found bipolar subjects higher in harm avoidance, and lower
in reward dependence, self-directedness, and cooperative-
ness than matched controls. The bipolar I subgroup speci-
cally was lower in reward dependence and cooperativeness
compared to controls, although eect sizes were weak. Now-
akowska et al. (2005), also using the TCI, found euthymic
bipolar I, bipolar II, and bipolar NOS outpatients higher
in novelty seeking, harm avoidance, and self-transcendence,
and lower in self-directedness than healthy subjects.
These data suggest that bipolar disorder may be associ-
ated with increased harmavoidance, increased novelty seek-
ing, decreased persistence, and decreased self-directedness.
However, studies of Cloninger et al.s (1993) dimensions
are dicult to compare due to sample selection biases, sam-
ple size dierences, and other methodological variation.
Some investigators have assessed inpatients (Strakowski
et al., 1992) while others have assessed outpatients (Osher
et al., 1999; Engstrom et al., 2004; Nowakowska et al.,
2005; Young et al., 1995). Not all have used standardized
diagnostic interviews to conrm a bipolar diagnosis (Osher
et al., 1999). Operational denitions of euthymia have var-
ied across studies (Osher et al., 1996; Engstrom et al., 2004).
Bipolar I and II patients have been combined in analyses
(Nowakowska et al., 2005) although their TCI proles are
not congruent, especially on the lower order personality
dimensions (Engstrom et al., 2004). Patients with substance
abuse comorbidities have been excluded from some samples
(Engstrom et al., 2004; Nowakowska et al., 2005). Finally,
investigators do not consistently covary for demographic
and clinical factors known to inuence TCI trait scores,
such as age, sex, educational level, and psychiatric symp-
toms (Mendlowicz et al., 2000).
The aim of the present study was to evaluate dierences
in TCI personality dimensions between recently recovered
bipolar I patients and healthy subjects, while controlling
for potentially confounding variables; and to examine
whether the TCI dimensions are independent of concurrent
mood state.
2. Methods and materials
2.1. Participants
The sample consisted of 85 bipolar I inpatients (n = 45)
and outpatients (n = 40) and 85 age and sex matched
healthy controls recruited from the community. Bipolar
patients were a subgroup among a larger cohort of partici-
pants in a two-year naturalistic study of the relationship of
neuropsychological decits to functional recovery in bipo-
lar disorder. Included in the larger cohort were individuals
1859 years old who were hospitalized for an acute aective
episode. Exclusion criteria were mental retardation, neuro-
logical disease, serious medical illness, and lack of uency
in the English language.
Two-thirds of the patient sample (n = 53, 62.4%) had at
least one comorbid axis I disorder; 37.6% (n = 32) reported
two or more. The most common comorbid diagnoses were
substance abuse or dependence (n = 46, 54.1%) followed by
anxiety disorders (n = 16, 18.8%). Patients mean age of ill-
ness onset was 22.52 years (SD = 6.35) and the average
duration of illness was 12.14 years (SD = 9.39). The mean
number of lifetime hospitalizations was 6.14 (SD = 5.19).
All subjects provided written informed consent after the
study procedures were fully explained to them.
2.2. Instruments
Bipolar patients were assessed with the Structured Clin-
ical Interview for DSM-IV-Patient Edition (SCID-I/P;
1132 S.T. Loftus et al. / Journal of Psychiatric Research 42 (2008) 11311136
First et al., 1996) by trained masters and doctoral-level
research assistants. Information gathered from the patient,
available colaterals, and the medical record was compiled
by the interviewer into a detailed case summary. This case
summary was presented to a committee of three senior
investigators who then rendered a consensus SCID diagno-
sis. Healthy controls were screened with the Structured
Clinical Interview for DSM-IV-Non-Patient Edition
(SCID-I/NP; First et al., 2001) to exclude lifetime axis I
disorders. In addition, they had no rst-degree relatives
with a history of psychiatric illness and presented with a
negative urine toxicology test for illicit substances.
All participants were administered the TCI, a 240 item
true/false questionnaire measuring Cloninger et al.s
(1993, 1994) four dimensions of temperament (novelty
seeking, harm avoidance, reward dependence, and persis-
tence) and three dimensions of character (self-directedness,
cooperativeness, and self-transcendence). Each of the seven
higher order dimensions is composed of three to ve lower
order facets or subcomponents of personality, yielding 25
subscales in all. For example, the temperament factor, nov-
elty seeking is composed of four subcomponents including
exploratory excitability, impulsiveness, extravagance, and
disorderliness; while the character dimension of self-direct-
edness is described by the lower order traits of responsibil-
ity, purposefulness, resourcefulness, self-acceptance, and
congruent second nature.
Concurrent aective symptoms were assessed monthly
in patients using the 17-item version of the Hamilton Rat-
ing Scale for Depression (HRSD-17; Hamilton, 1960) and
the Clinician-Administered Rating Scale for Mania
(CARS-M; Altman et al., 1994). Bipolar patients com-
pleted the TCI when their symptoms had improved to
within the mild range (dened by scores of 17 on the
HRSD-17 and 15 on the mania subscale (items 110) of
the CARS-M) to limit the degree to which state-related fac-
tors would aect personality ratings. The mean HRSD-17
score was 7.57 (SD = 4.92) and the mean CARS-M total
score was 6.83 (SD = 5.08). No subject met syndromal cri-
teria for a manic, mixed, hypomanic, or depressive episode
at the time the TCI was administered.
2.3. Statistical analyses
Independent t-tests and Pearson correlations were con-
ducted to examine the associations between age, sex, and
educational attainment and the seven TCI dimensions in
both subject groups. A multivariate analysis of covariance
(MANCOVA) was then performed to examine the dier-
ences between bipolar I patients and healthy controls on
the seven TCI dimensions, covarying for the eects of the
demographic factors.
To evaluate the state dependence of the instrument,
Pearson correlations were calculated between the seven
TCI dimensions and the HRSD-17 and CARS-M. A
MANCOVA controlling for demographic factors was used
to compare subjects treated for a manic vs. a depressive
episode at the index hospitalization on TCI traits. A second
MANCOVA controlling for demographic factors was used
to compare inpatient vs. outpatient subjects on TCI traits.
To control for multiple comparisons, a Bonferroni cor-
rected alpha was adopted (.05/7 = .007).
3. Results
3.1. Relationship of the TCI to demographic variables
There were no signicant dierences between the patient
and control groups with respect to age (34.82 10.19 vs.
34.53 10.25; t = .18, p = .85) and sex (42 vs. 40 females;
v
2
= .09, p = .76). Control participants, however, were
more highly educated than patients on average
(15.32 1.77 vs. 14.26 2.47 years; t = 3.21, p = .002).
There were no signicant relationships between the
seven TCI dimensions and the three demographic factors
in the patient group. In the control group, females were sig-
nicantly higher in self-directedness than males
(36.60 6.22 vs. 32.04 7.53; t = 3.01, p = .003).
3.2. Comparison of the TCI in bipolar I patients and healthy
controls
A MANCOVA comparing patients and controls on the
seven dimensions with diagnostic group as the independent
variable and age, sex, and education as covariates yielded a
main eect for group (F = 3.95, p < .001). Bipolar patients
were signicantly higher in harm avoidance, lower in self-
directedness, and higher in self-transcendence compared
to controls. Eect sizes were large for these three personal-
ity traits.
Post hoc analyses using a Bonferroni corrected alpha of
p < .002 (.05/25) revealed that patients and controls dif-
fered signicantly on 9 of the 25 of the lower order person-
ality dimensions. Three of the four harm avoidance
subscales, anticipatory worry, fear of uncertainty, and fati-
gability, were higher among patients than controls. Among
the self-directedness subscales, three of the ve scales were
lower among patients including responsibility, resourceful-
ness, and congruent second nature. Among the coopera-
tiveness subscales, only helpfulness was signicantly
lower in patients. Finally, among the self-transcendence
subscales, bipolar patients endorsed higher self-forgetful-
ness compared to controls. Table 1 summarizes the means
and standard deviations of the TCI scales and subscales,
and results of the multivariate analysis.
3.3. The state dependency of the TCI in bipolar I patients
Pearson correlations demonstrated that harm avoidance
was positively correlated with depressive symptoms
(r = 0.47, p < .001) and that self-directedness was nega-
tively correlated with depressive symptoms (r = 0.47,
p < .001). None of the seven scales was signicantly corre-
lated with the CARS-M total score; however, among the
S.T. Loftus et al. / Journal of Psychiatric Research 42 (2008) 11311136 1133
CARS-M subscales, persistence was positively correlated
with the mania subscale (items 110, M = 5.02 3.84;
r = .30, p = .006) and self-transcendence was positively
correlated with the psychosis subscale (items 1115,
M = 1.99 3.03; r = .29, p = .007).
Over half of the patient group (n = 52, 61.2%) was most
recently hospitalized for an episode of mania; approxi-
mately one-third (n = 25, 29.4%) had been hospitalized
for an episode of depression, and the remainder (n = 8,
9.4%) had been treated for a mixed episode. Patients most
recently hospitalized for mania were lower in harm avoid-
ance (16.00 7.01 vs. 21.64 7.59; F = 8.80, p = .004),
and higher in self-directedness (30.31 8.65 vs.
22.84 8.57; F = 10.71, p = .002) than depressed patients,
after controlling for demographic factors.
Fifty-three percent (n = 45) of patients completed the
TCI during the index hospitalization. The mean number
of months between hospitalization and TCI completion
was 3.29 (SD = 5.74). Patients who completed the TCI
while hospitalized were signicantly higher in persistence
than patients who completed the TCI after discharge
(5.78 1.61 vs. 4.53 2.12; F = 9.73, p = .003).
4. Discussion
This study compared bipolar I patients whose symptoms
had recently improved to euthymic/subsyndromal status
with healthy controls on temperament and character
dimensions. Patients responses reected higher harm
avoidance, lower self-directedness, and higher self-tran-
scendence scores than controls. Thus by their own report,
they appeared more fatigable, shy, worry prone, and pessi-
mistic. They endorsed less reliable and resourceful behav-
iors, which may lead them to be less able to eciently
pursue goals. Finally, they armed feeling highly creative
and spiritual. These results generally concur with those of
other research groups (Young et al., 1995; Nowakowska
et al., 2005).
All three of the traits distinguishing patients were corre-
lated with concurrent symptoms raising the question of
whether the TCI is a state-dependent measure. Our ndings
are consistent with studies of depressed samples that have
reported signicant correlations between harm avoidance
and depression and inverse relationships between depression
and self-directedness (Hansenne et al., 1999; Hirano et al.,
Table 1
Comparison of TCI dimensions in 85 bipolar I patients and 85 matched controls
Bipolar patients mean (SD) Healthy controls mean (SD) MANCOVA F-ratio df = (1, 165) P d/s
Novelty seeking 20.27 (5.76) 19.53 (4.87) 0.11 0.75 0.14
Exploratory excitability 6.44 (2.05) 7.05 (2.04) 4.69 0.03
Impulsiveness 4.35 (2.36) 3.49 (2.11) 3.92 0.05
Extravagance 5.08 (2.04) 4.85 (1.81) 0.03 0.85
Disorderliness 4.40 (2.00) 4.14 (1.88) 0.29 0.59
Harm avoidance 17.73 (7.63) 11.41 (6.68) 26.63 <0.001 0.88
Anticipatory worry 5.12 (2.77) 3.27 (2.40) 17.49 <0.001
Fear of uncertainty 4.44 (1.74) 3.08 (1.77) 24.16 <0.001
Shyness 3.86 (2.37) 2.66 (2.38) 7.53 0.007
Fatigability 4.32 (2.68) 2.40 (2.28) 19.28 <0.001
Reward dependence 15.96 (3.60) 15.75 (3.90) 0.41 0.53 0.06
Sentimentality 7.25 (2.19) 6.59 (2.13) 3.41 0.07
Attachment 5.14 (1.93) 5.32 (2.07) 0.09 0.76
Dependence 3.58 (1.43) 3.85 (1.45) 0.55 0.46
Persistence 5.19 (1.96) 4.95 (1.82) 1.28 0.26 0.12
Self-directedness 27.62 (9.05) 34.19 (7.27) 20.94 <0.001 0.80
Responsibility 5.48 (2.04) 6.87 (1.49) 20.85 <0.001
Purposefulness 5.25 (2.19) 6.15 (1.79) 7.52 0.007
Resourcefulness 3.19 (1.40) 4.15 (1.30) 14.46 <0.001
Self-acceptance 6.21 (2.85) 7.11 (3.07) 1.70 0.20
Congruent second nature 7.49 (3.17) 9.91 (2.26) 27.81 <0.001
Cooperativeness 31.08 (6.22) 33.18 (5.31) 2.55 0.11 0.36
Social acceptance 6.54 (1.45) 6.99 (1.49) 2.31 0.13
Empathy 5.20 (1.34) 5.48 (1.35) 0.86 0.35
Helpfulness 5.33 (1.30) 6.00 (1.08) 11.15 0.001
Compassion 7.71 (2.26) 7.79 (2.34) 0.15 0.70
Pure-heartedness 6.31 (1.93) 6.92 (1.42) 2.14 0.15
Self-transcendence 16.32 (6.25) 12.21 (6.96) 16.13 <0.00 0.62
Self-forgetfulness 5.74 (2.81) 3.80 (2.48) 21.17 <0.001
Transpersonal
Identication 3.41 (2.08) 2.57 (2.20) 7.37 0.007
Spiritual acceptance 7.16 (2.98) 5.85 (3.57) 6.96 0.009
1134 S.T. Loftus et al. / Journal of Psychiatric Research 42 (2008) 11311136
2002; Richter et al., 2000). Supporting the position that these
particular traits may be state dependent, reductions in
depressive symptoms have been accompanied by decreases
in harm avoidance and increases in self-directedness when
measured in the same patients longitudinally (Chien and
Dunner, 1996; Hirano et al., 2002; Joe et al., 1993).
High harm avoidance has been the most consistent nd-
ing across bipolar studies and appears to be associated with
the subsyndromal depression experienced by many patients
in interepisode periods (Judd et al., 2002). Harm avoidance
is posited to be linked to serotonin by Cloninger (1987),
which is implicated in depressive states. Serotonergic dys-
regulation may underlie both the chronic depressive symp-
toms and harm avoidant tendencies found in this
population. Akiskal and colleagues (1983) delineate four
possible relationships between personality and aective ill-
ness. To illustrate with harm avoidance: high harm avoid-
ance may (a) signal a vulnerability to developing an
aective disorder; (b) result from current state related
changes in mood; (c) represent a scarring eect of illness
in which the elevation remains after the resolution of symp-
toms or; (d) independently modify the expression of
symptoms.
Lower self-directedness in patients as compared to con-
trols was also found by Nowakowska et al. (2005). How-
ever, lower self-directedness is not specic to bipolar
disorder. It extends to other psychiatric samples (Klump
et al., 2004; Lyoo et al., 2001) and may be an artifact of ill-
ness. Higher levels of depression may also explain the lower
self-directedness scores in our sample, but we could not
clarify the role of current symptoms in contributing to
group dierences as symptom levels were not assessed in
the healthy subjects.
In addition, we found severity of psychosis related to
self-transcendence. Bipolar patients arming high self-
transcendence may give unusual, imaginative and idiosyn-
cratic interpretations to events that are associated with
psychotic thought processes and/or the hyperreligious ide-
ation accompanying mania. According to Cloninger et al.s
(1994) character theory, high self-transcendence in the
presence of high self-directedness leads to a mature creativ-
ity and spirituality. However, as noted by Bayon et al.
(1996), who found self-transcendence positively correlated
with the Millon scales, delusions and mania, high
self-transcendence in the presence of low self- directedness
may suggest a proneness to psychosis. Thus the greater self-
transcendence scores in our sample may reect residual
symptoms rather than the transpersonal consciousness pro-
posed by Cloninger et al. (1993, 1994).
Our results dier markedly from those of Engstrom
et al. (2004), who reported dierences between bipolar I
patients and controls on reward dependence and coopera-
tiveness only. Apart from the state-dependency issue
already noted, sample selection might account for the
opposing results. Engstrom et al. (2004) assessed euthymic,
lithium monotherapy outpatients who did not present with
a substance abuse disorder. Our sample, in contrast, was
comprised of recently recovered individuals, 62% of whom
suered from an axis I comorbidity (with 54% carrying a
lifetime substance abuse or dependence diagnosis). The
bipolar subjects in our study likely presented with more
complicating illness features, which could be the result of
a more pronounced temperamental prole or cause greater
scarring eects on personality.
We did not conrm others ndings of either higher
(Nowakowska et al., 2005; Young et al., 1995) or lower
(Osher et al., 1999) novelty seeking, and lower persistence
(Osher et al., 1996; Osher et al., 1999) in bipolar patients.
This lack of replication might be due to dierences in cur-
rent mood state among the samples, the limited sample
sizes used in previous studies, or the neglect to control
for demographic variables that have demonstrated rela-
tionships with the TCI (Mendlowicz et al., 2000). Although
not a temperamental dierence between patients and con-
trols here, we found persistence higher in inpatients vs. out-
patients and signicantly correlated with manic symptoms.
The perseverant and goal directed behaviors characteristic
of high persistence appear to increase when patients are in
a manic or hypomanic state.
Our study is limited by its cross-sectional design, the het-
erogeneity of the bipolar group (i.e., inpatient and outpa-
tient; high degree of comorbidity), and lack of symptom
measures among the healthy subjects. Future studies that
are both prospective and longitudinal in nature, assess
patients when euthymic, and account for demographic
and clinical variables aecting personality measurement
are necessary to disentangle the relationship between state
and trait. Such designs may determine whether there is a
temperamental vulnerability to developing a mood disor-
der as a sibling pair study indicates (Farmer et al., 2003),
whether mood disorders inuence personality, or whether
there exists a complex interplay of both processes on neu-
rodevelopment over the lifespan.
Role of the funding source
Funding for this study was provided by NIMH Grant
R01MH 60904-02 (Judith Jaeger, Ph.D., M.P.A., Principal
Investigator) and the Stanley Medical Research Institute.
The NIMH and the Stanley Medical Research Institute
had no role in the study design; in the collection, analysis,
and the interpretation of the data; in the writing of this
report; and in the decision to submit it for publication.
Contributors
This study was based upon Dr. Loftuss psychology doc-
toral dissertation and was an addition to Dr. Jaegers
NIMH grant entitled, Targeting Disabilities for Rehabil-
itation in Bipolar Disorder. Dr. Loftus undertook the lit-
erature review and designed the study. Dr. Loftus and
members of Dr. Jaegers sta collected the patient data.
Dr. Malhotra provided the healthy control data. Dr. Lof-
tus and Dr. Garno ran the statistical analyses and wrote
S.T. Loftus et al. / Journal of Psychiatric Research 42 (2008) 11311136 1135
the manuscript. Dr. Jaeger and Dr. Malhotra provided
guidance on subsequent drafts. All authors have approved
of the nal manuscript.
Conicts of interest
Dr. Shay Loftus, Dr. Jessica Garno, Dr. Judith Jaeger,
and Dr. Anil Malhotra declare that they have no conicts
of interest that could inappropriately inuence their work
and the research report submitted here.
Acknowledgements
The authors wish to thank Drs. Stefanie Berns, Rebecca
Ianuzzo, Pradeep Nagachandran, and Sandra Yecker and
Mr. Sherif Abdelmessih, Ms. Cristina Gonzalez, Mr. Scott
Greisberg, Ms. Priya Matneja, and Ms. Giovanna Musso
for their contributions to the data collection and manage-
ment of this project. We also thank Dr. John Cecero of
Fordham University, Bronx, NY for his support as disser-
tation mentor.
References
Akiskal HS, Hirschfeld RM, Yerevanian BI. The relationship of person-
ality to aective disorders. Archives of General Psychiatry
1983;40:80110.
Altman EG, Hedeker DT, Janicak PG, Peterson JL, Davis JM. The
clinician- administered rating scale for mania (CARS-M): development
of reliability and validity. Biological Psychiatry 1994;36:12434.
Bayon C, Hill K, Svrakic DM, Pryzbeck TR, Cloninger CR. Dimensional
assessment of personality in an out-patient sample: relations of the
systems of Millon and Cloninger. Journal of Psychiatric Research
1996;30:34152.
Chien AJ, Dunner DL. The tridimensional personality questionnaire in
depression: state versus trait issues. Journal of Psychiatric Research
1996;30:217.
Cloninger CR. A systematic method for clinical description and classi-
cation of personality variants. Archives of General Psychiatry
1987;44:57388.
Cloninger CR, Pryzybeck TR, Svrakic DM. The tridimensional person-
ality questionnaire: US normative data. Psychological Reports
1991;69:104757.
Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of
temperament and character. Archives of General Psychiatry
1993;50:97590.
Cloninger CR, Pryzybeck TR, Svrakic DM, Wetzel RD. The temperament
and character inventory (TCI): a guide to its development and use. St.
Louis, MO: Washington University, Center for Psychobiology of
Personality; 1994.
Dunayevich E, Strakowksi SM, Sax KW, Sorter MT, Keck PE, McElroy
SL, et al. Personality disorders in rst- and multiple-episode mania.
Psychiatry Research 1996;64:6975.
Engstrom C, Brandstrom S, Sigvardsson S, Cloninger CR, Nylander P-O.
Bipolar disorder III. Temperament and character. Journal of Aective
Disorders 2004;82:1314.
Farmer A, Mahmood A, Redman K, Harris T, Sadler S, McGun P. A
sib-pair study of the temperament and character inventory scales in
major depression. Archives of General Psychiatry 2003;60:4906.
First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical
interview for the DSM-IV-TR axis I disorders patient edition (SCID-
I/P). Biometrics Research Department, New York State Psychiatric
Institute; 1996.
First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical
interview for the DSM-IV-TR axis I disorders non-patient edition
(SCID-I/NP). Biometrics Research Department, New York State
Psychiatric Institute; 2001.
Hamilton M. A rating scale for depression. Journal of Neurology and
Neurosurgery 1960;23:5662.
Hansenne M, Reggers J, Pinto E, Kjiri K, Ajamier A, Ansseau M.
Temperament and character inventory (TCI) and depression. Journal
of Psychiatric Research 1999;33:316.
Hirano S, Sato T, Narita T, Kusunoki K, Ozaki N, Kimura S, et al.
Evaluating the state dependency of the temperament and character
inventory dimensions in patients with major depression: a methodo-
logical contribution. Journal of Aective Disorders 2002;69:318.
Hirschfeld RMA, Klerman GL, Lavori P, Keller MB, Grith P, Coryell
W. Premorbid personality assessments of rst onset of major depres-
sion. Archives of General Psychiatry 1989;46:34550.
Hirshfeld RMA, Klerman GL, Clayton PJ, Keller MB, McDonald-Scott
P, Larkin BH. Assessing personality: eects of the depressive state on
trait measurement. American Journal of Psychiatry 1983;140:6959.
Joe RT, Bagby RM, Levitt AJ, Regan JJ, Parker JDA. The tridimen-
sional personality questionnaire in major depression. American
Journal of Psychiatry 1993;150:95960.
Judd LL, Akiskal HS, Schettler PJ, Endicott J, Maser J, Solomon DA,
et al. The long-term natural history of the weekly symptomatic status
of bipolar I disorder. Archives of General Psychiatry 2002;59:5307.
Klump KL, Strober M, Bulik CM, Thornton L, Johnson C, Devlin B,
et al. Personality characteristics of women before and after recovery
from an eating disorder. Psychological Medicine 2004;34:140718.
Lozano BE, Johnson SL. Can personality traits predict increases in manic
and depressive symptoms? Journal of Aective Disorders
2001;63:10311.
Lyoo IK, Lee DW, Kim YS, Kong SW, Kwon JS. Patterns of
temperament and character in subjects with obsessive-compulsive
disorder. Journal Clinical Psychiatry 2001;62:63740.
Maj M, Del Vecchio M, Starace F, Pirozzi R, Kemali D. Prediction of
aective psychoses response to lithium prophylaxis. Acta Psychiatrica
Scandinavica 1984;69:3744.
Mendlowicz MV, Girardin J-L, Gillin JC, Akiskal HS, Furlanetto LM,
Rappaport MH, et al. Sociodemographic predictors of temperament
and character. Journal of Psychiatric Research 2000;34:2216.
Nowakowska C, Strong C, Santosa C, Wang PW, Ketter T. Tempera-
mental commonalities in euthymic mood disorder patients, creative
controls, and healthy controls. Journal of Aective Disorders
2005;85:20715.
Osher Y, Cloninger CR, Belmaker RH. TPQ in euthymic manic-
depressive patients. Journal of Psychiatry Research 1996;30:3537.
Osher Y, Lefkifker E, Kotler M. Low persistence in euthymic manic-
depressive patients: a replication. Journal of Aective Disorders
1999;53:8790.
Peselow ED, Sanlipo MP, Fieve RR. Relationship between hypomanic
personality disorders before and after successful treatment. American
Journal of Psychiatry 1995;152:2328.
Richter J, Eisemann M, Richter G. Temperament and character during
the course of unipolar depression among inpatients. European
Archives of Psychiatry and Clinical Neuroscience 2000;250:407.
Solomon DA, Shea TM, Leon AC, Mueller TI, Coryell W, Maser JD,
et al. Personality traits in subjects with bipolar I disorder in remission.
Journal of Aective Disorders 1996;40:418.
Strakowski SM, Faedda GL, Tohen M, Goodwin DC, Stoll AL. Possible
aective-state dependence of the tridimensional personality question-
naire in rst-episode psychosis. Psychiatry Research 1992;41:21526.
Swendsen J, Hammen C, Heller T, Gitlin M. Correlates of stress reactivity
in patients with bipolar disorder. American Journal of Psychiatry
1995;152:7957.
Young LT, Bagby M, Cooke RG, Parker JDA, Levitt AJ, Joe RT. A
comparison of tridimensional personality questionnaire dimensions in
bipolar disorder and unipolar depression. Psychiatry Research
1995;58:13943.
1136 S.T. Loftus et al. / Journal of Psychiatric Research 42 (2008) 11311136

You might also like