1 UNIVERSITÀ DI PISA
Dipartimento di Medicina Clinica e Sperimentale
SCUOLA DI SPECIALIZZAZIONE IN PSICHIATRIA
Direttore: Prof.ssa Liliana Dell’Osso
TESI DI SPECIALIZZAZIONE
Emotional dysregulation in cyclothymic patients:
psychopathological definition and associated clinical features
CANDIDATO
RELATORE
Dott. Corrado Cerliani
Prof. Giulio Perugi
2
Emotional dysregulation in cyclothymic patients:
psychopathological definition and associated clinical features
Summary
Emotional dysregulation in cyclothymic patients: psychopathological
definition and associated clinical features ... 2
Introduction ... 4
Features ... 7
Chronobiology ... 14
Cyclothymia and Bipolar Disorder... 16
Cyclothymia and neurodevelopment ... 20
Cyclothymia and comorbidity ... 21
Aim of the Study ... 22
Materials and Methods ... 23
Sample ... 23
Data Collection ... 24
Assessing Instruments ... 24
Statistical analysis ... 26
3
Demographics ... 30
Comorbidity ... 31
Family History for Axis-I disorders in first-degree relatives ... 31
Treatment ... 32 Psychometric evaluations ... 32 Further evaluations ... 33 Discussion ... 34 Limitations ... 42 Conclusions ... 42 Tables ... 44 References ... 54
4 Introduction
Cyclothymia, among mood disorders, is probably the most neglected, at least in epidemiological studies. Although the rates of prevalence in general population are reported to be between 0,4% and 2,5% (Van Meter, Youngstrom et al. 2012), and even higher in psychiatric patients, research in mood disorders has prevalently focused on bipolar disorder, major depression and dysthymia. This is probably due to the ambiguity regarding the conceptualization of cyclothymia and the common tendency to describe it only in terms of mood symptoms. Current diagnostic classifications (DSM-5, ICD-10) include cyclothymia as a separate category among bipolar disorders. DSM defines cyclothymic disorder as “numerous periods of hypomanic symptoms and numerous periods of depressive symptoms that do not meet symptom or duration criteria for a major depressive episode” suggesting an alternation in time between symptoms of the two polarities. Additionally, if an individual with cyclothymic disorder experiences a major depressive or a manic episode, the diagnosis is dropped and the patient is reclassified as BD-I or BD-II, therefore seeing cyclothymic disorder as either a residual category, a prodrome or a “forme fruste” of a Bipolar Disorder. ICD-10, similarly, states that it is an “A persistent instability of mood involving numerous periods of depression and mild elation, none of which is sufficiently severe or prolonged
5 to justify a diagnosis of bipolar affective disorder or recurrent depressive disorder. This disorder is frequently found in the relatives of patients with bipolar affective disorder. Some patients with cyclothymia eventually develop bipolar affective disorder.” On the other hand, others have classified it as an affective temperament (Akiskal et al., 1979), or even as a personality style (Brieger and Marneros, 1997; Parker, 2011). The categorical approach provides an arbitrary clear-cut separation between cyclothymic and BD II and I disorders. In clinical practice, most cyclothymic patients are referred for major affective episodes, but if a cyclothymic subject experiences a major depressive or a (hypo)manic episode, the diagnosis is dropped and the patient is reclassified as BD I or BD II. In this context, cyclothymia is viewed as a residual category, while its clinical importance and independent profile is left unappreciated. Moreover, a definition based only on the long-lasting alternation of mood-symptoms of opposite polarity neglects most of the behavioral and psychological features of the disorder and its continuity with temperamental and personality characteristics. Mood reactivity and affective instability, extreme emotionality and impulsivity, which should be considered as true core features of cyclothymia, as well as most of their psychological, behavioral and interpersonal consequences are described from a different perspective in the DSM-5 criteria for dramatic or anxious clusters of personality disorders and in the ICD-10 definition of emotionally unstable and histrionic personality disorders. This approach represents a major
6 limitation for understanding not only the relationship between constitutional traits and major episodes in mood disordered patients, but also the close link between cyclothymia and other anxious and impulse control disorders, with relevant implications for their treatment and clinical management.
Behavioral and psychological aspects of cyclothymia, as well as the associated comorbidity, should be considered major targets for an integrative management strategy. “Minor” mood swings don’t necessarily mean a lighter impact on one’s life and behavior, as cyclothymia, being a pattern starting in late childhood or first adolescence, tends to be a stable trait throughout all the span of people’s lives, sometimes leading to a consistent interference in many fields of life. In its core essence, cyclothymia is a stable and somewhat homogeneous pattern of symptoms, whose main factor in determining the impact on functioning is the instability of the mood – psychomotricity complex. That basically consists in a scarcely predictable instability between states of high energy, elevated volition and activity and periods characterized by apathy, lethargy and behavioral inhibition. From this nuclear feature, a number of other more complex manifestations stems forth. Such other features are completely overlooked both DSM and ICD’s diagnostic criteria for the syndrome, leading inevitably to an under-diagnosis of this phenomenon and a potential misinterpretation of its symptoms. The correct recognition of a putative cyclothymic matrix in these “complex” clinical presentations constitutes a fundamental step to implement effective and
7 integrative treatment strategies. Thus, despite cyclothymia requires more sophisticated treatments than do classical bipolar I and II disorders, its proper operationalization remains an obscure area in psychiatry research. The evidence on psychological and pharmacological treatments in this area is very sparse so that, even when cyclothymia is correctly identified, there is neither evidence-based treatment, nor consensus on the strategy to treat it. The development of therapies for mood disorders mainly focuses on treating and preventing major mood episodes but not addressing minor thymic oscillations in an affordable way in terms of tolerability.
Features
Nuclear features
Analyzing the features of the emotional dysregulation of cyclothymic patients can give further insight into its nature. Though the core feature of cyclothymia is an impaired regulation of the stability of mood and activity, some subdimensions are detectable. Endogenous and exogenous instability, a predominant polarity in the baseline mood and emotional intensity can, first of all, distinguish cyclothymia from other temperaments. Depue et al. (1981) indicated that the most frequent items for cyclothymia —in large part derived from Akiskal et al. (1977), (1979) — were ‘lethargy alternating with eutonia’,
8 ‘marked unevenness in quantity and quality of productivity’ and ‘mental confusion alternating with sharpened and creative thinking’. This shows how the main field in which the swings can be observed is not mood itself, but rather the amount of energy and the ability to successfully focus it into effective thinking and acting.
Cyclothymia is also characterized by a lower response threshold both to external and internal stimuli, and more intense and lasting emotional reactions. In this light, this kind of mood swings can be interpreted as something halfway between physiologic mood regulation and the major episodes of bipolar disorder.
Cloninger’s subdimensions
Relating to Cloninger’s personality dimensions, cyclothymia has been shown to score high both in Harm Avoidance and in Novelty Seeking (Maremmani and Akiskal 2005), in an apparently conflicting way. The co-presence of harm avoidance in individuals with high novelty seeking has been hypothesized, from an evolutionary perspective, to be some kind of security valve protecting against the dangers of the most extremes of risk-taking (Akiskal and Akiskal, 2005).
9
Behavioral features
The interaction of the core traits of cyclothymia with the environment gives often rise to some recurrent behaviours, which nonetheless are not listed or considered diagnostic features for the disorder. Interpersonal sensitivity often triggers excessive hostile reactions towards the ones perceived as hurting, leading to disruption in the texture of interpersonal relationships. Separation anxiety determines a dependent attachment, with frantic efforts to determine a real or imagined abandonment, and dramatic reactions in such situations. Also, this can impair an individual’s ability to acknowledge when it is healthy to truncate a relationship. Similar effects are determined by the excessive need to please other people, configuring a “toxicomanic” attitude towards appreciation and its behavioral consequences, sometimes with submissiveness and sometimes with a peculiar kind of altruism mainly enacted for the sake of its façade. Romantic relationships can become complicated by an insecure attachment (MacDonald, Berlow et al. 2013), with cyclothymics feeling the need for constant reassurance and testing repeatedly the firmness of the bond. The perception of self-image is labile, shifting abruptly from satisfactory to frustrating in response to environmental feedback, often with an overreaction to mild cues. The erratic nature of the cyclothymic’s global reactions to various stimuli can be perceived with distress, generating a sort of affective “perplexity” due to the fact that the same stimulus can elicit different
10 reactions in different moments, on the basis of the current mood state. In other words, the affective value of an input is seldom twice the same. Something exciting can become dull within short time, something neutral can become hurtful and so on. This leads to two main outcomes: first of all cyclothymics feel a strong need for psychological explanations of this “uncertainness”, as many perceive this instability as egodystonic. The second consequence is a stronger drive towards stimuli that have a constant pleasant connotation: substances and behavioral addictions. Coupled with a greater impulsiveness this explains the predicting value of the cyclothymic temperament towards addictions (Maremmani, Pacini et al. 2009, Pacini, Maremmani et al. 2009, Pani, Maremmani et al. 2010).
The main and most frequent trigger of a strong mood reaction in a cyclothymic is the area of interpersonal relationships: it is not rare for a cyclothymic to value social and romantic life way above the other aspects of life. High novelty seeking prompts them strongly to seek reward from new relationships, while the anxious components of interpersonal sensitivity and separation anxiety interact with the strong harm avoidance tendency giving way to ruminations about the loved one, strong interpretation of subtle to nonexistent signs and thus, sometimes, a general loss of grip on the ability to read correctly social inputs by the loved one.
11
Interpersonal sensitivity
According to Boyce and Parker (Boyce and Parker 1989), interpersonal sensitivity is defined as undue and excessive awareness of, and sensitivity to, the behavior and feelings of others. Individuals with this trait are preoccupied with their interpersonal relationships, vigilant to the behavior and moods of others, overly sensitive to perceived or actual criticism or rejection, and their behavior is modified with other's expectations to minimize the risk of criticism or rejection. As a predictor it has been associated to nonmelancholic and atypical phenotypes in depression (Boyce, Hickie et al. 1993). Furthermore, it associates with harm avoidance, reward dependence, persistence and transcendence, and correlates negatively with self-directedness (Otani, Suzuki et al. 2008). Invariably, the lability of mood in cyclothymia carries with itself a high interpersonal sensitivity (Perugi, Toni et al. 2003, Perugi, Fornaro et al. 2011), leading the affected individuals to be easily wounded and offended. Hyper-reactivity to judgment, criticism and rejection with consequent interpersonal sensitivity are very common manifestations of cyclothymia. When emotional reactions are particularly intense, a tendency to be interpretative and to develop overvalued ideas may episodically appear, with heavy consequences on social and interpersonal relationships. Similarly, the fragile self-esteem associated to the fear of being disapproved, rejected or abandoned may lead to submissive behaviours and
12 persistent involvement in abusive relationships. A pathological dependence on compliments and emotional reward is often observed, sometimes in association with inappropriate seductive, provocative and manipulative behaviors. These manifestations may complicate the patient-doctor relationship. Cyclothymics are inclined to adopt behaviours apt to limit the harm coming from criticism, often becoming manipulative and privileging relationships in which control makes them feel more at ease, and often shying away from the ones less inclined to fall for the manipulative tactics. This strategy aims at controlling separation anxiety, but strongly conflicts with the other main aspect of a cyclothymic personality: novelty seeking. Novelty seeking individuals have the urge to go for strong emotions, and tend to like more unpredictable and independent people, thus losing swiftly interest in people “kept at bay” in the aforementioned way. This is one of the factors that leads to the cyclothymics’ trademark stormy romantic lives, especially during adolescence and early adulthood. Still, interpersonal sensitivity plays yet another role in this field, generating hostility towards all the perceived injurers, either by means of overperception of critics or frustration of expectations. This can stir instances of vengefulness, reported and rationalized subjectively in terms of a strong sense of justice and a will to “rightly get even”.
13 Yet another key feature of cyclothymia is separation anxiety (Del Carlo, Benvenuti et al. 2013), which is strongly interweaved with interpersonal sensitivity, as with mood instability and with reactivity (Pini, Abelli et al. 2005, Perugi, Toni et al. 2012). Separation anxiety is defined as excessive anxiety regarding separation from home or from people to whom the individual has a strong emotional attachment. The idea of the possibility of such an event arouses in these patients a strong anguish. A significant correlation between separation anxiety, interpersonal sensitivity and cyclothymic mood instability has been demonstrated in several studies in adults with mood and anxiety disorders (Perugi et al., 2003; Toni et al., 2008). In particular, the link between childhood and/or adult separation anxiety and mood instability has been confirmed by various research groups in different populations (Pini et al., 2005; Toni et al., 2008). Fear of being disapproved, rejected or turned away and anxiety upon separation, with their negative emotional consequences, are a fertile soil for the genesis of submissive behavior and persistent involvement in abusive relationships. On the other hand, the tendency to please others with excessive dedication may result in forms of conduct definable as ‘pathological altruism’. The oscillation between complacency and excessive feelings of anger-hostility may have a negative impact on romantic relationships, family life or employment, which become more and more difficult and unstable (Hantouche and Perugi, 2012). Another source of subjective and interpersonal distress is the difficult coexistence of opposite
14 and conflicting attitudes with temperamental traits such as a high level of novelty seeking and harm avoidance (Signoretta et al., 2005).
Chronobiology
Mood disorders are often associated with alterations of sleep and circadian rhythm through a complex and mutual relationship (Schnell, Albrecht et al. 2014). A link between sleep disorders, circadian rhythmicity, chronotype preference, residual mood symptoms and mood episode recurrence has emerged in bipolar patients (Cretu, Culver et al. 2016). Chronotype or morningness / eveningness is the individual preference of the day's period for carrying out activities (Vitale, Roveda et al. 2015). It reflects the propensity for the individual either to be alert or to sleep through the 24 hours. Three main chronotypes have emerged: morning types, evening types and intermediate (Diaz-Morales, Escribano et al. 2015).
Circadian rhythm and sleep disruptions are tightly linked to mood disorders (Malhi and Kuiper 2013, Bechtel 2015), with alterations that are often phase-specific: reduced sleep need is a feature often observed in mania, while depressive episodes are usually associated with insomnia, usually central or terminal in the melancholic subtype, and initial if anxiety levels are higher; hypersomnia, instead, is more frequent in atypical depression (Kanady,
15 Soehnera et al. 2015). Moreover, sleep loss has been identified as a marker which increases suicide risk in patients with a suicide attempt history (Stange, Kleiman et al. 2016).
Among the different chronotypes, mood disorders seem to be mostly related to eveningness. A stuy by Seleem et al. (Seleem, Merranko et al. 2015) demonstrated that evening preference is a chronic characteristic in bipolar patients. In this study, evening preference was not associated with polarity type, or mood state in bipolar disorder, suggesting that this characteristic may be a trait marker. Six studies involving 850 patients showed that evening type was more common in bipolar patients as compared to controls (Ahn, Chang et al. 2008, Wood, Birmaher et al. 2009, Giglio, Magalhaes et al. 2010, Boudebesse, Lajnef et al. 2013, Kim, Weissman et al. 2014, Baek, Kim et al. 2016). No difference in circadian preference was found between chronotypes of bipolar and unipolar patients (Chung, Lee et al. 2012).
With respect to bipolar subtypes, (Baek, Kim et al. 2016) revealed that bipolar II patients had higher eveningness scores than bipolar I patiens even during euthymia. Considering the higher prevalence of cyclothymic temperament among bipolar II patients, it is reasonable to assume that higher emotional instability may be linked to a sharper evening preference. This also emerges from the rapid cycling subtype, that compared to non-rapid cycling bipolar disorder shows that rapid cycling patients are more likely to have evening preference (p < 0.02) (Mansour, Wood et al. 2005). Again, bipolar
16 adolescents (ages 13 y and older) endorsed greater eveningness compared to controls, similar to adults with bipolar bisorder (Kim, Weissman et al. 2014). Cyclothymic temperament has directly been linked with a delayed sleep onset (Ottoni, Antoniolli et al. 2012), showing that evening types had less emotional control, coping, volition, and caution, and more affective instability and externalization. Again evening-type was significantly associated with greater depressive, cyclothymic, irritable, and anxious temperaments, while morning-type was significantly associated with hyperthymic temperament (Park, An et al. 2015).
Cyclothymia and Bipolar Disorder
The relationship between cyclothymic temperament and bipolar disorder are expressed at different levels. The temperamental disposition:
can be considered a vulnerability factor for the onset of a full-blown bipolar episode and most comorbid conditions;
may influence the course of bipolar disorder and the clinical expression of depressive, manic or mixed episodes;
requires a specific approach for the treatment and management of the concomitant mood disorder.
17 Both DSM-5 and ICD-10 recognize that cyclothymic disorder is often observed in the relatives of bipolar patients and that some patients with cyclothymia eventually develop bipolar disorder. The observation of cyclothymic temperament in children and adolescents with depression has been considered one of the strongest predictor for the further development of bipolar disorder (Kochman, Hantouche et al. 2005).
In adults, cyclothymic temperament is considered an expression of bipolar diathesis and has been associated with frequent depressive or mixed-depressive recurrences (Nilsson, Straarup et al. 2012). Cyclothymic temperamental features such as “mood lability”, “energy activity”, and “daydreaming” have been proved to be specific in identifying unipolar depressives who switched to hypomania (Akiskal, Maser et al. 1995).
According to Koukopoulos (Koukopoulos, Sani et al. 2006), two main clusters of features can be observed in bipolar patients: the first includes hyperthymic temperament, endogenous cyclicity, the MDI sequence (Mania– Depression-Interval cycle), and the good prophylactic action of lithium, which is probably accomplished through the reduction of the degree of the hyperthymia during free intervals. The second includes cyclothymic temperament (excitable and labile affective traits), exogenous cyclicity, prevalence of bipolar II disorder, the DMI sequence, and rapid cycling. This mood instability produces frequent alternations of excitement and depression and, eventually, a continuous autonomous circular course. The main clinical
18 problem is observed in many cases when rapid cyclicity persists beyond the first year of adequate treatment.
“Cyclothymic depression” is probably the most common manifestation of bipolarity, as it regards at least the 50% of depressed outpatients in psychiatric settings (Hantouche, Akiskal et al. 1998). Similar findings have been reported in depressive patients in general medical practice (Manning, Haykal et al. 1997). Cyclothymia can be observed in bipolar I patients, but more commonly it is associated with bipolar disorder II. In a French study on major depression, 88% of subjects with cyclothymic features belonged to the bipolar II subtype (Hantouche, Akiskal et al. 1998). In the largest proportion of these subjects, cyclothymic temperament is present since childhood or adolescence, but clear clinical manifestations may be triggered by stressful life events later in life at any age. From this perspective cyclothymia is the temperamental foundation (“basic state”) of many bipolar II depressions. Depressive phases usually dominate the clinical presentation or, anyway, cyclothymic patients only report depressive symptoms being scarcely aware of the hypomanic phases. Despite this, hypomania is very common (Koukopoulos, Sani et al. 2006) and mostly characterized by irritability, disinhibited and impulsive behavior, rather than elation or euphoria.
The “primacy” of cyclothymic temperament is also reflected by its influence on the bipolar disorder course in terms of cyclicity, comorbidity and complications such as suicidality and drug resistance. Cyclothymia is
19 associated with early onset of bipolar disorder in childhood or adolescence and with extreme spontaneous or medication-induced mood cyclicity and instability (Akiskal, Djenderedjian et al. 1977, Perugi and Akiskal 2002, Koukopoulos, Sani et al. 2006). Finally, emotional dysregulation associated with cyclothymic temperament and other neurodevelopmental disorders seems to represent the most common substrate of the high comorbidity rates with anxiety, impulse control, and also with alcohol and substance use disorders (Perugi and Akiskal 2002, Pani, Maremmani et al. 2010, Powers, Russo et al. 2013) frequently observed in bipolar samples and in patients with neurodevelopmental disorders (Perugi, Ceraudo et al. 2013, Vannucchi, Masi et al. 2014).
As concerns the clinical presentation of the bipolar disorder episodes, ”cyclothymic depression” frequently shows atypical features such as hypersomnia, hyperphagia, inverse diurnal variations and marked fatigue (‘leaden paralysis’) (Davidson, Miller et al. 1982, Perugi, Akiskal et al. 1998, Benazzi 1999, Perugi, Toni et al. 2003). Atypical features are often accompanied by a variety of associated features strictly related to the underlying emotional dysregulation: mood reactivity, interpersonal sensitivity, separation anxiety, panic and phobic anxiety, obsessive-compulsive symptoms, somatizations, self-pity, subjective or overt anger, jealousy, suspiciousness, and overvalued ideas (Akiskal, Maser et al. 1995).
20 Cyclothymic temperamental instability may play a very crucial role in suicidal behaviors observed in many bipolar patients. Mood reactivity, with rapid shift from inhibition to disinhibition, might represent the constitutional basis providing the energy and drive necessarily associated with suicidal acts. Suicidality is frequently a reactive and sometime impulsive behavior triggered by real, perceived or delusional problems in different areas (usually interpersonal relationships, financial concerns, health). The prominent role of constitutional mood instability in the development of suicidal behavior has been supported by multiple research studies, reporting that cyclothymic temperament is linked to significantly higher number of past suicide attempts in patients with mood disorders (Akiskal, Akiskal et al. 2006, Mechri, Kerkeni et al. 2011). This association has been confirmed for different types of suicidal behavior (violent and nonviolent attempts, suicidal ideation) and in different samples (mood disorder patients, suicide attempters) (Pompili, Rihmer et al. 2009).
Cyclothymia and neurodevelopment
Emotional dysregulation, characterized by intense and rapid mood changes of both polarities and by the tendency to over-react to external stimuli, especially within the interpersonal field, represents the temperamental
21 basis of cyclothymia. Different degrees of emotional dysregulation, associated with changes of energy and motivation, are described in cluster B personality disorders and in all neurodevelopmental disorders. The fact that all these conditions share with cyclothymia a difficulty in modulating their behavior during emotional states suggests a plausible common neurophysiological basis. A number of studies reported structural as well as functional abnormalities in the neural network subserving emotional information (i.e., amygdala hyper-reactivity in concert with regulatory deficits of the orbito-frontal cortex and the prefrontal cortex) suggest that emotional arousal interferes with cognitive processing in borderline personality disorder subjects (Domes, Schulze et al. 2009, Ruocco, Amirthavasagam et al. 2013). Consistently with the notion of reduced emotional regulation, even patients with bipolar disorder and mood instability showed over-activation within the parahippocampus/amygdala and thalamus and reduced engagement within the ventrolateral prefrontal cortex (Delvecchio, Sugranyes et al. 2013). In other terms, some neurodevelopmental dysfunctions of amygdala and fronto-limbic circuitries may represent the common neurophysiological substrate of the emotional dysregulation involved in different and apparently separated clinical entities.
22 The bond between cyclothymia and panic disorder has been thoroughly investigated in literature (Perugi, Toni et al. 2012, Del Carlo, Benvenuti et al. 2013, Altinbas, Altinbas et al. 2015), showing how this temperament is strongly represented in individuals with panic disorder.
Previous literature has shown how cyclothymic temperament seems to be a key factor in the development and maintenance of addictive behaviour, and patients with alcohol or heroin dependence can be sorted out from healthy control group on the basis of cyclothymic traits (Maremmani, Pacini et al. 2009) (Pacini, Maremmani et al. 2009). From another perspective, cyclothymic temperament is the most inherently morbid and prodromal towards behavioral and emotional problems (Signoretta, Maremmani et al. 2005).
Some studies associated somatoform disorder with subdimensions of cyclothymic temperament. It has been linked with harm avoidance, novelty seeking, reward dependence and self-directedness (Yamano, Fukuda et al. 2010) (Frolund Pedersen, Frostholm et al. 2016) (Karvonen, Veijola et al. 2006), sensitive temperament (Bujoreanu, Randall et al. 2014), and a global disposition towards affective temperaments (Amann, Padberg et al. 2009).
23 Aim of the present study was to obtain a thorough investigation on the factors and the features implied in the emotional dysregulation typical of cyclothymia, in particular:
To further probe the subdimensions of the emotional dysregulation To check for association patterns with the base features of cyclothymia and more structured constructs like separation anxiety
To retrieve a possible trademark chronotype in cyclothymia
To search association with demographic variables and clinical features.
Materials and Methods
Sample
We recruited 131 individuals with diagnosis of cyclothymia, divided as follows: 87 are followed in the outpatient unit of our clinic, 44 are non-patients. The mean age was 34,39 (st. dev. 12,463), 65 are females and 66 males (M:F ratio = 1,015). Each individual completed the following scales: Brief TEMPS-M (Erfurth, Gerlach et al. 2005), RIPoSt (Hantouche 2010), ASA-27 (Manicavasagar, Silove et al. 2003). 57 of them completed the MEQ-SA questionnaire (Horne and Ostberg 1976). Sociodemographic characteristics and illness history were collected during the interview by highly
24 trained physicians. All the data was analyzed with the Statistical Package for Social Sciences (SPSS) v.20.
Data Collection
All the patients included in the study have undergone an assessment session performed by residents of the Specialization School of Psychiatry, supervised by expert psychiatrists of the research group which provided the first diagnostic overview of the patients and the subsequent evaluation for specific comorbidities. Diagnosis of cyclothymia and evaluation of DSM’s diagnostic criteria for Borderline Personality Disorder and Antisocial Personality Disorder were performed clinically. The Brief TEMPS-M was used for a more precise profiling of temperamental dimensions. The RIPoSt questionnaire was used to assess the emotional features and further probe the underlying mood dysregulation. Adult separation anxiety was recorded through the ASA-27 questionnaire, and the evaluation of the chronotype was obtained by administering the MEQ-SA scale. Finally, the SIMD-R was used to collect the participants' demographic and retrospective clinical data of patients with mood disorders.
Assessing Instruments
Reactivity Intensity Polarity Stability Questionnaire (RIPoSt) (Hantouche Elie, 2010): the RIPoSt is a 60-items self-administered questionnaire exploring the
25 emotional dimension in its various components. The scale is composed of 4 subscales: reactivity, intensity (the usual force), polarity and stability of emotions, each of whom characterized by 15 items. It can be a useful tool for measuring the emotional features and providing an assessment of the degree of emotional dysregulation.
Semi-structured Interview for Mood Disorders (SIMD-R) (Cassano, Akiskal et al. 1989): the SIMD-R is a semi-structured diagnostic interview for assessment of mood disorders. It systematically collects information on different familiar, demographics, medical history and clinical aspects. This interview has been developed to gather systematic information on family history, previous episode number and polarity, suicide attempts (current and lifetime), and psychotic symptoms of any polarity. Thanks to this tool it was also possible checking the main affective diagnosis and the type of mood episode currently in progress. Whenever possible, collateral clinical data, including information obtained from other informants as well as any available past medical records, were used to support patient information, and in particular, to corroborate the onset age and polarity of the participants' first illness episode.
Temperament Evaluation of Memphis, Pisa, Paris and San Diego-M (Munster translation by Erfurth) (Brief TEMPS-M) (Erfurth et al. 2005): it is a 35-items self-administered questionnaire exploring affective and anxious temperaments. Each question provides for a 5-point Likert scale (from absent to very much). The patient is asked to specify for each question the value better describing his/her feelings during the majority of the life. Five temperaments are explored: depressive, cyclothymic, hyperthymic, irritable and anxious.
26 Adult Separation Anxiety Questionnaire (ASA-27) (Manicavasagar, Silove et al. 2003): ASA-27 is a 27-item self-report questionnaire that purports to examine symptoms of separation anxiety experienced after 18 years of age, with Likert ratings on a scale of zero (this never happens) to three (this happens very often).
Morningness-Eveningness Questionnaire Self Admnistered (Horne and Ostberg 1976): it is a self rating questionnaire made of 19 items, aiming at defining the individual circadian orientation (evening, morning or intermediate chronotype). Items explore the most recent weeks before the administration. The 19 items have multiple answers with scores ranging from 0 to 6. The direct sum of the scores yields the chronotype based on a stratification in five ranges. From lowest to highest score it divides probands in the following groups: strong evening-type, moderate evening-type, intermediate, moderate morning-type, strong morning-type.
Statistical analysis
Linear regression scores were used to relate the subdimensions of the RIPoSt scale to the other scales administered (Brief TEMPS-M, ASA-27 and MEQ-SA), as well as to the number of criteria the probands met for Antisocial and Borderline personality disorders. A factorial reduction was then performed on the scores of the Brief Temps scale, yielding two factors. Based on the prevalence of either the first or the second factor in terms of loading the probands were then divided in two groups, and t-tests (Mann-Whitney’s U-test when variance significantly differed) were performed on continuous
27 variables, while chi-square tests were used on categorical variables. Finally, a second factorial reduction was performed on the scores of the RIPoSt subscale. Statistical significance was set at p < 0.05. All the data was analyzed with the Statistical Package for Social Sciences (SPSS) v.20.
Results
Linear regression scores were used to relate subdimensions of the RIPoSt subscale with the Brief Temps-M scale, the ASA-27 and the MEQ-SA scale.
The emotional reactivity subscale showed a positive correlation with the temperaments Dysthymic (p = 0.000), Irritable (p = 0.000), Cyclothymic (p = 0.010) and Anxious (p = 0.014). It also correlated with separation anxiety traits (p = 0.000) and withy the number of criteria for Borderline (p = 0.001) and Antisocial (0.025) personality disorder. It showed no correlation with the Hyperthymic temperament and neither with the tendency to morningness. (Table 1)
The emotional intensity subscale correlated positively with the temperaments Dysthymic (p = 0.000), Cyclothymic (p = 0.000), Irritable (0.000) and Anxious (0.000), as well as with separation anxiety (p = 0.000) and with the number of criteria for Borderline personality disorder (p = 0.009). It
28 showed no correlation with Hyperthymic temperament, morningness tendency and the number of criteria for Antisocial personality disorder. (Table 2)
The negative emotionality subscale correlated positively with the temperaments Dysthymic (p = 0.000), Cyclothymic (p = 0.000), Irritable (p = 0.000) and Anxious (p = 0.000), as well as with separation anxiety (p = 0.000) and the number of criteria for Borderline personality disorder. It also showed a negative correlation with Hyperthymic temperament (p = 0.002). It did not relate to the morning chronotype or the criteria for Antisocial personality disorder. (Table 3)
The positive emotionality subscale correlated positively only with the Hyperthymic temperament (p = 0.000), and showed no kind of correlation to the other temperaments, separation anxiety, chronotype or the criteria for personality disorders. (Table 4)
Lastly, the emotional stability subscale (whose score increases with endogenous instability) showed a positive correlation with the temperaments Dysthymic (p = 0.000), Cyclothymic (p = 0.000), Irritable (p = 0.000) and Anxious (p = 0.000). It also correlated with separation anxiety (p = 0.000) and with the number of criteria for Borderline personality disorder (p = 0.023). It showed no correlation with the Hyperthymic temperament, chronotype or the criteria for Antisocial personality disorder. (Table 5)
29 A factorial reduction with Varimax rotation (Kaiser normalization) was then performed on the scores of the Brief TEMPS-M scale, yielding two factors, the first of which explained 48,510% of the total variance, while the second explained 22,045%, with a total of the 70,555% of the global variance explained by these two components. The first factor loaded as follows:
0,814 on the Dysthymic temperament, 0.805 on the Cyclothymic temperament -0.148 on the Hyperthymic temperament 0.633 on the Irritable temperament 0.833 on the Anxious temperament
The second factor yielded by the reduction loaded as follows: -0.140 on the Hyperthymic temperament
0.015 on the Cyclothymic temperament 0.922 on the Hyperthymic temperament 0.463 on the Irritable temperament -0.132 on the Anxious temperament
Factor loadings are shown in Table 6.
We then assigned all the patients a categorical variable based on the prevalence of either the first or the second component, which we labeled respectively “dark” and “sunny”. We used this categorization to perform
30 Student’s t-tests on the other continuous variables (Mann-Whitney’s U test if Levene’s variancy test was significant), and chi-square test on categorical variables.
Demographics
People with a predominance of the dark factor were significantly more prone to being treated in our outpatient unit (p = 0.000) and female (p = 0.001). No significant age difference was found, neither there was any in the marital status. The chi square on the educational level showed a significance of p = 0.004 with the following results
Predominantly dark group: 9% post-graduation, 45% graduation, 37% tertiary school, 8% secondary school and 1% primary school
Predominantly sunny group: 1% post-graduation, 21% graduation, 56% tertiary school, 21% secondary school, 1% primary school
No difference was found in terms of areas of residence or family type. A significant difference was found in the occupation type with p = 0.022, with
Predominantly dark group: 36% student, 14% unemployed, 16% housewife, 1% factory worker o farmer, 13% artisan or trader, 16% employee, teacher or career military, 1% manager or entrepreneur or freelance and 3% retired.
31 Predominantly sunny group: 35% student, 18% unemployed, 3% housewife, 5% factory worker or farmer, 1% artisan or trader, 27% employee or teacher or career military, 10% manager or entrepreneur or freelance and 1% retired.
See Table 7 for further data.
Comorbidity
The dark group showed significantly higher rates of major depressive disorder (p = 0.010), bipolar II disorder (p = 0.002) and social phobia (p = 0.007), and a nearly significant higher rate of panic disorder (p = 0.057). The sunny group showed a significantly higher rate of cannabis abuse (p = 0.050) and a nearly significant rate of global substance abuse (p = 0.063). No correlations were found for bipolar I disorder, seasonal course, alcohol abuse, stimulants abuse, opiates abuse, simple phobia, obsessive-compulsive disorder, eating disorders, impulse control disorders, premenstrual dysphoric disorder or onset age for Axis-I disorders. Table 8
Family History for Axis-I disorders in first-degree relatives
Only a family history generalized anxiety disorder showed a prevalence in the dark group with p = 0.014. No correlation was found for major
32 depressive disorder, bipolar disorder, alcoholism, substance abuse, schizophrenia, social phobia, panic disorder, obsessive-compulsive disorder, eating disorders or impulse control disorders. Table 9
Treatment
People belonging to the dark group had a significantly higher chance of having been treated, during their lives, with tricyclic antidepressants (p = 0.031), SSRIs (p = 0.000), mood-stabilizing anticonvulsants (p = 0.000) and benzodiazepines (0.034). No significant association was found with antipsychotics (either first or second generation), Lithium, psychotherapy or electroconvulsive therapy. Table 10
Psychometric evaluations
The dark group scored significantly higher in the RIPoSt subscales Emotional reactivity (p = 0.000), Emotional intensity (p = 0.000), Negative emotionality (p = 0.000) and Emotional intability (p = 0.000). It also scored higher in the separation anxiety as per the ASA-27 questionnaire (p = 0.000). The sunny group scored higher in the RIPoSt subscale Positive emotionality (p = 0.005). No significant difference was found in the scores of the
33 chronotype recorded by the MEQ-SA questionnaire and in the number of criteria for Borderline and Antisocial disorder.
Further evaluations
Although the criteria for borderline and antisocial personality disorders didn’t significantly relate with the categorical variables we created, a significant correlation through linear regression emerged between the numerical scores of the dark subtype and the fulfilled number of criteria for the diagnosis of borderline personality disorder with B = 0,714 and p=0.000. The same happened for the number of criteria for antisocial personality disorder with B = 0,268 and p = 0,011 The number of criteria for Antisocial Personality also correlated with the sunny factor, with B = 0,206 and p = 0,046. We also found that the scores of the MEQS-A were predicted by the values of the “Sunny” factor closely to significance, so that the higher the factor loading was, the more the morning preference was pronounced (B = 3,315, p = 0,063). As a last investigation we performed the same factorial reduction with Varimax rotation (Kaiser normalization) on the RIPoSt scale, obtaining these loadings as reported in Table 12. The first factor loaded:
0.917 on the Emotional Reactivity subscale 0.869 on the Emotional Intensity subscale
34 0.854 on the Negative Emotionality subscale
0.040 on the Positive Emotionality subscale 0.840 on the Emotional Instability subscale
While the second factor loaded
0.073 on the Emotional Reactivity subscale 0.335 on the Emotional Intensity subscale -0.314 on the Negative Emotionality subscale 0.981 on the Positive Emotionality subscale 0.044 on the Emotional Instability subscale
Discussion
The results from the linear regression show a clustering of depressive, cyclothymic and anxious temperaments, as well as separation anxiety and criteria for borderline and antisocial personality disorders. Each one of these seems to relate to a general instability / intensity pattern, which is the core definition of emotional dysregulation. Hyperthymic temperament instead seems to relate to the predominant emotional polarity with a direct proportionality (positively with positive emotionality and vice versa negatively with the negative emotionality), having apparently no bond with endogenous instability, exogenous reactivity and emotional intensity. Interestingly, it didn’t
35 show a negative correlation with the three latter dominions, apparently suggesting that general instability and intensity travel on a railway independent from baseline mood polarity. We then performed a factorial reduction on the temperamental scores obtained through the Brief TEMPS-M scale. The first question that arose was about the nature of the two factors obtained. Given all enrolled subjects were clinically classified as having cyclothymia, two possible explanations are viable: either some hyperthymic subjects were enrolled into the study, or cyclothymia is not a unitary and homogeneous entity and a predominant polarity can be retrieved even in an unstable temperament. Studies on the validation of the TEMPS scale in the general population in which a factorial reduction was performed showed a slightly different loading of the hyperthymic factor with other temperamental dimensions. In two studies the hyperthymic component shows a negative correlation with the cyclothymic temperament (Bloink, Brieger et al. 2005, Dolenc, Dernovsek et al. 2015), whereas the sunny factor of our sample shows a positive, although weak, loading on the cyclothymic subscale. Another study (Rozsa, Rihmer et al. 2008) performed a similar operation, obtaining two factors rotated with Varimax that showed similar loadings on the temperamental subscales, nonetheless in this study the “sunny” factor showed a moderately positive loading (0.338) on the cyclothymic dimension, similar to the loading on the irritable scale (0.395). The “dark” factor, instead, shows similar loadings to ours. A noteworthy result we obtained is the
36 correlation between the sunny component and the rate of cannabis abuse, further distinguishing it from the hyperthymic temperament, which has shown to be a protective factor against substance abuse (Rovai, Maremmani et al. 2017). In general it looks like the temperament has a nature different from the five categorical instances proposed, and it can be probably better expressed in terms of two main components: predominant polarity and tendency to dysregulation. According to our results with the RIPoSt scale the predominant feature of the dark component seems to be the emotional instability, both in its exogenous and endogenous manifestations. Being more unstable seems to necessarily imply a greater deal of anxiety and above all negative emotions. On the other hand, people who show a more stable mood are indeed more prone to feeling satisfied and tranquil. Irritability, instead, seems to be a really different component with no specificity for any of the factors, in our and in other studies on temperament (Bloink, Brieger et al. 2005, Rozsa, Rihmer et al. 2008). If we represent this on a scatter plot it looks clear that the two components are not mutually exclusive, instead a comprehensive pattern appears Figure 1.
We could rethink the distribution of temperaments based on these two variables, where the sunny factor (Y-Axis in the plot) represents the predominant mood polarity and could be a risk factor towards externalizing disorders and impulsiveness (in our sample we lacked an impulsivity scale and enough BD type 1 patients, but we had a result in substance use disorders),
37 and the dark factor (the X-Axis) represents the emotional dysregulation, accounting for the risk of developing internalizing disorders, notably depressive states, whether in the context of MDD or BD type2 disorders, and depressive equivalents such as anxiety disorders. The sunny factor is likely to be a predictor for expansive phases too, as such it unsurprisingly had a male prevalence in our sample. Temperaments as classically intended can be seen as an intermediate syndromic construct standing between these two factors and the full blown Axis I disorders. More precisely, hyperthymic temperament shows a specific overlapping with the sunny factor, much more than the dark factor with its cyclothymic, dysthymic and anxious correlates. In this light, the latter three can be just seen as different phenotypes of the same innate trait. As such, risk factors for Axis I disorders are homogenous within the whole “dark” group. The factorial reduction performed on the RIPoSt subscale yielded two strikingly similar factors, proving those are likely to be actual entities and not just an artifact due to the formulation of the Brief TEMPS-M scale.
Coming to analyze the demographic features it appears the female gender is correlated with the dark factor, while males tend to be more oriented towards the sunny component. This is consistent with the demographics of affective disorders (Perugi, Musetti et al. 1990, Benazzi 2006), with the predominance of type 2 bipolar disorder in females and type 1 in males, and an overall prevalence of depression and depressive equivalents
38 in females, while males show a tendency towards the expansive polarity. The dark component also strongly correlates with seeking clinical help: subjects enrolled outside of our patient unit were more likely to have a predominant sunny component. This can be attributed both to a greater deal of comorbidity in the dark subtype and to a major egodistonicity of its features and its comorbidities. Age didn’t show a specific correlation with either subtype, ruling out the possibility that the two subtypes could be age-specific or different temporal phases of the same nosological entity; they appear, instead, to be a stable trait throughout one’s life. Interestingly, dark cyclothymics had a significantly higher educational level than sunny ones. Again, given the mean age of the two groups was very similar, this effect cannot be attributed to a bias due to the time in life in which subjects were evalutated, meaning that it is possible that the dark component pushes toward a higher educational level. Opposite evidence is found in a study by Schmidt et al. (Schmidt, Rodrigues et al. 2010), saying educational level was lower in depressives and higher in euthymics and hyperthymics. A correlation between a polymorphism of the 5-HTTLPR and affective temperament has been found in literature (Gonda, Fountoulakis et al. 2009), and that same gene has an implication in other temperamental and demographic variables, among which the educational level (Saiz, Garcia-Portilla et al. 2010). On the other hand, the sunny subtype has turned out to be more frequent among professionals with jobs commonly perceived to be more anxiety-generating,
39 such as freelance, manager and entrepreneur. This result can be explained with lower levels of psychic anxiety in these individuals and better tolerance to stressors. Literature relates this feature to classic hyperthymic temperament (Maremmani, Dell'Osso et al. 2010). Clinical comorbidities highlighted a predictable pattern of the more depressive kind of disorders (Bipolar Type 2 and Unipolar Depression) among the dark subtype, a feature largely expected on the basis of existing literature which relates instability to depression (Akiskal, Maser et al. 1995, Koukopoulos, Sani et al. 2006, Nilsson, Straarup et al. 2012), showing our data is in line with the main authors on the subject. Same for anxiety disorders: social phobia has been linked to neuroticism and mood reactivity (Naragon-Gainey, Gallagher et al. 2013). A Finnish meta-analysis linked social phobia with low novelty seeking scores (Miettunen and Raevuori 2012), whereas as noted before, cyclothymics as a whole tend to have high rates in social phobia and in novelty seeking. The two subgroups emerged could possibly separately account for these correlations, in this respect it would be interesting to relate them to Cloninger’s personality subdimensions. Substance abuse, as noted before, tends to be associated with cyclothymia (Rovai, Maremmani et al. 2017). Considering comorbidities, the two factors that emerged from our sample both account for disorders in which cyclothymia represents a risk factor, more specifically the dark and sunny group seem to relate separately and more specifically to internalizing and externalizing (respectively) well-established comorbidities of cyclothymia.
40 The pertinence of both subgroups to cyclothymia is further confirmed by a lack of statistical significance in the age of onset of Axis I disorders, when present; whereas in case of different temperaments the age of onset would differ: cyclothymic temperament has been shown to lower significantly the age of onset of Axis I disorders (Akiskal, Hantouche et al. 2003). In terms of treatment, the main link to the dark subtype appears with drugs acting on anxiety, meaning anxiety disorders could mediate the presence of the preponderance of the dark factor and the drive of these subjects to seek clinical help. A link also appears with anticonvulsant mood stabilizers, which is comprehensible given the dark factor is the main cause of rapid mood swings, but not with lithium, which is usually prescribed when well defined major manic and mixed episodes are present. The role of lithium in rapid mood swings and cyclothymia appears to be less brilliant than in bipolar disorders (Peselow, Dunner et al. 1982), with hyperthymic temperament reported as a predictor of efficacy of this drug (Rybakowski, Dembinska et al. 2013). Lithium remains nonetheless effective in preventing complications such as suicidality even in cyclothymic patients (Yerevanian, Koek et al. 2003). The number of criteria for Cluster B personality disorders Borderline and Antisocial, which we used as a numerical variable, is predicted by the score in the dark factor, meaning the more dysregulated emotionality is, the more the personality pattern is likely to align to these two phenotypes. Affective lability in borderline patients has received quite some attention in literature, and to
41 day is a well established feature (Skodol, Siever et al. 2002). Interestingly, both disorders related to the emotional dysregulation represented by the dark factor, but only the Antisocial personality disorder related to the sunny factor. This is very likely due to the formulation of diagnostic criteria for this disorder, which focuses heavily on impulsiveness and acted reactions (anger, impulsiveness, dangerous behaviors), whereas the criteria for Borderline personality disorder rely more on identifying cognitive cues such as self-image and negative emotionality and anxiety. This perspective may strengthen the possible predictive role of the sunny factor for impulsiveness and a general higher level of psychomotor baseline activation. DSM reports a male prevalence of Antisocial personality disorder. Our sample reports a nearly significant correlation of the sunny factor score with male gender (p = 0,063 on Mann-Whitney’s U-test), and a strong correlation of the dark factor with female gender ( t = -4,255 p = 0,000). The sunny parameter likely mediates whether the dysregulative behavior of these patients tends to assume a more externalized (antisocial) or internalized (borderline) pattern, consistently to literature findings of a prevalence of males in high baseline psychomotor-mood polarity (hyperthymic) and a prevalence of females in the unstable (depressive – anxious – cyclothymic) cluster (Erfurth, Gerlach et al. 2005). Lastly, the tendency to morningness was predicted by high scores in the sunny factor in a close-to-significance pattern (p = 0.06), while eveningness (lower scores on the scale) was close to correlation with the dark factor (p = 0.09).
42 The number of people who completed the MEQ-SA was lower than the other questionnaires as it was added later to the protocol. The tendency emerging from the data seems to suggest that a higher baseline mood-psychomotricity is related to phase anticipation, while the emotional dysregulation is tied to a delay in the sleep phase. This result is in line with the literature regarding the link between chronotypes and affective temperament, with hyperthymia relating to morningness and the depressive – anxious – cyclothymic cluster relating to eveningness (Park, An et al. 2015, Chrobak, Tereszko et al. 2017).
Limitations
The sample size of our study was relatively small. We also lacked direct measurements of impulsiveness and other features of the externalizing cluster, which may have given promising results. Self-reports are also prone to a bias in wiping off the most undesirable traits of one’s personality, especially in a sample of probands with high interpersonal sensitivity.
Conclusions
The structure of cyclothymia can be satisfyingly defined by a combination of two variables: the variation in intensity of baseline
mood-43 psychomotor tone and the exaggerated emotional reactivity. Among the classical comorbidities of cyclothymia these two factors account for the risk of having co-occurrent disorders and other psychopathological features. Emotional reactivity tightly relates to all internalizing comorbidities of cyclothymia, while a highly intense variations of baseline mood-psychomotor tone is very likely to predict externalizing psychopathological features such as (hypo)manic episodes and impulsiveness. Cluster B personality disorders Borderline and Antisocial appear to be different from cyclothymia not in terms of quality but just in quantity of the loadings of the two factors proposed. Widening the sample size, probing the other temperaments and expanding the gamut of dimensions evaluated could give better insight into mood regulation, whether it be physiological or pathological, and retrieve a more precise risk assessment for major comorbidities and a better tailoring of treatments. Also, the organic counterpart of the two factors hereby individuated makes for a good research target. With any luck, a biological correlate of these two factors could emerge, furthering our understanding of the functioning of human brain.
44 Tables
Table 1: Linear regression correlations of RIPoSt subdimension Emotional Reactivity
Scale B β p
Dysthymic (Brief TEMPS-M) 0.546 0.272 0.000 Irritable (Brief TEMPS-M) 0.730 0.357 0.000 Hyperthymic (Brief TEMPS-M) -0.40 -0.96 0.280 Cyclothymic (Brief TEMPS-M) 0.340 0.194 0.010 Anxious (Brief TEMPS-M) 0.333 0.188 0.014 Separation Anxiety (ASA-27) 0.489 0.597 0.000 Borderline PD Criteria 2.123 0.339 0.001 Antisocial PD Criteria 2.469 0.222 0.025 Morningness (MEQ-SA) -0.128 -0.123 0.360
Table 2: Linear regression correlations of RIPoSt subdimension Emotional Intensity
Scale B β p
Dysthymic (Brief TEMPS-M) 0.692 0.360 0.000
Cyclothymic (Brief TEMPS-M) 0.537 0.321 0.000
Hyperthymic (Brief TEMPS-M) -0.013 -0.029 0.747
Irritable (Brief TEMPS-M) 0.678 0.347 0.000
Anxious (Brief TEMPS-M) 0.824 0.486 0.000
Separation Anxiety (ASA-27) 0.388 0.496 0.000
Borderline PD Criteria 1.527 0.259 0.009
Antisocial PD Criteria 0.008 0.079 0.431
45 Table 3: Linear regression correlations of RIPoSt subdimension Negative Emotionality
Scale B β p
Dysthymic (Brief TEMPS-M) 0.861 0.730 0.000
Cyclothymic (Brief TEMPS-M) 0.445 0.432 0.000
Hyperthymic (Brief TEMPS-M) -0.390 -0.278 0.002
Irritable (Brief TEMPS-M) 0.405 0.334 0.000
Anxious (Brief TEMPS-M) 0.568 0.545 0.000
Separation Anxiety (ASA-27) 0.249 0.521 0.000
Borderline PD Criteria 1.034 0.287 0.004
Antisocial PD Criteria 0.022 0.143 0.156
Morningness (MEQ-SA) -0.135 -0.085 0.535
Table 4: Linear regression correlations of RIPoSt subdimension Positive Emotionality
Scale B β p
Dysthymic (Brief TEMPS-M) -0.116 -0.111 0.216
Cyclothymic (Brief TEMPS-M) 0.082 0.068 0.450
Hyperthymic (Brief TEMPS-M) 0.540 0.477 0.000
Irritable (Brief TEMPS-M) 0.050 0.049 0.586
Anxious (Brief TEMPS-M) -0.097 -0.082 0.360
Separation Anxiety (ASA-27) -0.124 -0.046 0.608
Borderline PD Criteria 0.013 0.037 0.713
Antisocial PD Criteria -0.024 -0.123 0.223
46 Table 5: Linear regression correlations of RIPoSt subdimension Emotional Instability
Scale B β p
Dysthymic (Brief TEMPS-M) 1.397 0.541 0.000
Cyclothymic (Brief TEMPS-M) 1.868 0.830 0.000
Hyperthymic (Brief TEMPS-M) -0.025 -0.077 0.391
Irritable (Brief TEMPS-M) 0.939 0.357 0.000
Anxious (Brief TEMPS-M) 1.262 0.554 0.000
Separation Anxiety (ASA-27) 0.539 0.521 0.000
Borderline PD Criteria 1.764 0.227 0.023
Antisocial PD Criteria 0.014 0.190 0.058
Morningness (MEQ-SA) -0.181 -0.254 0.057
Table 6: Factorial reduction of the scores of Brief TEMPS-M and loading on the temperamental subscales
Temperament Component 1 (“Dark”) Component 2 (“Sunny”)
Dysthymic 0,814 -0,140
Cyclothymic 0,805 0,015
Hyperthymic -0,148 0,922
Irritable 0,633 0,463
47 Table 7: Comparison of demographic variables in the predominantly dark and predominantly sunny groups
Dark Sunny t or χ2 p In therapy (N=128) 54 (84%) 30 (46%) 19,948 0,000 Gender: Male (N=128) 23 (36%) 41 (64%) 10,125 0,001 Mean Age (s.d.) (N=128) 36,38 (13,267) 32,83 (11,545) 1,613 0,109 Marital Status (N=104) 3,692 0,159 Single 34 (74%) 45 (82%) Married 9 (20%) 4 (7%) Divorced / Separed 3 (6%) 6 (11%) Educational Level (N=128) 15,343 0.004 Post-Graduation 6 (9%) 1 (1%) Graduation 27 (45%) 13 (21%) Tertiary 22 (37%) 36 (56%) Secondary 5 (8%) 13 (21%) Primary 1 (1%) 1 (1%)
48 Table 7-bis: Comparison of demographic variables in the predominantly dark and predominantly sunny groups
Dark Sunny t or χ2 p Residence (N=109) 1,767 0,413 Urban 23 (47%) 34 (60%) Suburban 22 (45%) 20 (35%) Rural 4 (8%) 3 (5%) Family Type (N=104) 2,073 0,355 Parental / Collateral 24 (52%) 22 (40%) Conjugal 13 (28%) 16 (29%) Alone 9 (20%) 17 (31%) Job (N=127) 16,431 0,022 Student 23 (36%) 21 (35%) Unemployed 9 (14%) 11 (18%) Housewife 10 (16%) 2 (3%) Factory worker / Farmer 1 (1%) 3 (5%) Artisan / Trader 8 (13%) 1 (1%) Employee / Teacher / Career military 10 (16%) 16 (27%)
Manager / Entrepreneur / Freelance 1 (1%) 5 (10%)
49 Table 8: Comorbity rates in the predominantly dark and predominantly sunny groups
Dark Sunny t or χ2 p
Major Depressive Disorder (N=123) 16 (26%) 5 (8%) 6,549 0,010 Bipolar Disorder Type I (N=123) 4 (6%) 6 (9%) 0,367 0,545 Bipolar Disorder Type II (N=123) 22 (37%) 8 (13%) 9,347 0,002 Seasonal Course (N=114) 23 (40%) 23 (40%) 0,24 0,878 Substance Abuse (N=123) 15 (24%) 25 (40%) 3,468 0,063 Alcohol Abuse (N=123) 3 (4%) 2 (3%) 0,226 0,635 Opiates Abuse (N=123) 2 (3%) 5 (8%) 1,312 0,252 Stimulants Abuse (N=123) 4 (6%) 10 (16%) 2,793 0,095 Cannabis Abuse (N=123) 12 (20%) 22 (35%) 3,843 0,050 Social Phobia (N=123) 13 (21%) 3 (4%) 7,373 0,007 Simple Phobia (N=123) 13 (21%) 19 (30%) 1,392 0,238 Panic Disorder (N=123) 31 (50%) 21 (33%) 3,619 0,057 OCD (N=123) 2 (3%) 2 (3%) 0,000 0,987 Generalized Anxiety (N=123) 10 (16%) 8 (13%) 0,300 0,584 Any Eating Disorder (N=123) 10 (16%) 6 (9%) 1,226 0,268 Restrictive Anorexia (N=123) 5 (8%) 3 (4%) 0,570 0,450 Binging-Purging Anorexia (N=123) 2 (3%) 2 (3%) 0,000 0,987 Bulimia (N=123) 8 (13%) 4 (6%) 1,591 0,213 Impulse Control Disorder (N=123) 5 (8%) 8 (13%) 0,721 0,396 Premenstrual Dysphoria (N=53) 19 (65%) 14 (58%) 0,288 0,591 Axis I Onset Age (s.d.) (N=93) 23,78 (9,667) 22,61 (10,643) 0,539 0,592
50 Table 9: Axis-I disorder ratios in first degree relatives in the predominantly dark and predominantly sunny groups
Dark Sunny t or χ2 p Major Depressive Disorder (N=124) 20 (32%) 19 (30%) 0,37 0,847
Bipolar Disorder (N=124) 22 (35%) 16 (25%) 1,366 0,243 Alcoholism (N=124) 3 (5%) 3 (5%) 0 1 Substance Abuse (N=124) 1 (1%) 4 (6%) 1,876 0,171 Schizophrenia (N=124) 0 (0%) 2 (3%) 2,033 0,154 Social Phobia (N=124) 5 (8%) 2 (3%) 1,363 0,243 Panic Disorder (N=124) 15 (24%) 12 (19%) 0,426 0,514 OCD (N=124) 0 (0%) 0 (0%) - - Generalized Anxiety (N=124) 18 (29%) 7 (11%) 6,062 0,014 Anorexia (N=124) 1 (1%) 2 (3%) 0,342 0,559 Bulimia (N=124) 1 (1%) 1 (1%) 0 1
51 Table 10: Treatment prevalence in the predominantly dark and predominantly sunny groups Dark Sunny t or χ2 p Tricyclic Antidepressants (N=106) 23 (48%) 16 (27%) 4,668 0,031 SSRI Antidepressants (N=107) 33 (67%) 17 (29%) 15,437 0.000 Anticonvulsants (N=107) 33 (68%) 20 (33%) 12,860 0,000 Benzodiazepines (N=106) 29 (59%) 22 (38%) 4,473 0,034
First Generation Antipsychotics (N=104) 9 (19%) 10 (17%) 0,044 0,833
Second Generation Antipsychotics (N=104) 15 (32%) 10 (17%) 2,913 0,088
Lithium (N=104) 8 (17%) 11 (19%) 0,089 0,765
Psychotherapy (N=100) 18 (40%) 18 (32%) 0,568 0,451
52 Table 11: Scoring of the predominantly dark and predominantly sunny groups in psychometric scales
Dark Sunny t or χ2 p
Emotional Reactivity (RIPoSt)
N=128 57,08 (s.d. 12,093) 47,41 (s.d. 12,177) 4,509 0,000
Emotional Intensity (RIPoSt)
N=128 59,31 (s.d. 11,566) (s.d.12,089) 51,20 3,878 0,000
Negative Emotionality (RIPoSt)
N=127 29,20 (s.d. 5,755) 21,29 (s.d. 7,536) 6,762 0,000
Positive Emotionality (RIPoSt)
N=127 26,86 (s.d. 6,205) 29,94 (s.d. 5,817) 2,882 0,005
-Emotional Instability (RIPoSt)
N=128 56,23 (s.d. 14,780) 41,05 (s.d. 15,176) 5,736 0,000
Adult Separation Anxiety (ASA-27) N=124 34,82 (s.d. 14,439) 19,08 (s.d. 13,979) 6,166 0,000 Borderline PD Criteria N=99 3,00 (s.d. 1,850) 2,87 (s.d. 2,067) 0,333 0,740 Antisocial PD Criteria N=99 0,41 (s.d. 0,858) 0,53 (s.d. 1,120) 0,568 0,571 -Morningness (MEQ-SA) N=57 43,05 (s.d. 11,142) 48,17 (s.d. 12,423) 1,577 0,121
-53 Table 12: Factorial reduction of the scores of RIPoSt and loading on subscales.
Subscale Component 1 (“Dark”) Component 2 (“Sunny”)
Emotional Reactivity 0.917 0.073
Emotional Intensity 0.869 0.335
Negative Emotionality 0.854 -0.314
Positive Emotionality 0.040 0.981
Emotional Instability 0.840 0.044
