# 2008 The Authors Journal compilation # 2008 Blackwell Munksgaard
Acta Neuropsychiatrica 2008: 20: 295–299 All rights reserved DOI: 10.1111/j.1601-5215.2008.00335.x
ACTA NEUROPSYCHIATRICA
Affective temperament in stroke patients Kurt E, Karacan I, Ozaras N, Alatas G. Affective temperament in stroke patients. Objective: The aims of this study were to determine the dominant affective temperament changes in stroke survivors and whether temperament affects the disability. Methods: A total of 63 stroke patients were included in this study. Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire was used to determine the dominant affective temperament (depressive, hyperthymic, cyclothymic, irritable or anxious). The disability level was measured with the Barthel index (BI). Results: Depressive temperament (17.5%) and anxious temperament (12.7%) were the most common dominant affective temperaments. The frequencies of irritable, cyclothymic and hyperthymic temperaments were 4.8, 3.2 and 0%, respectively. The mean BI score was 78.1 18.3 in patients with depressive temperament and 67.4 28.4 in patients without depressive temperament (p ¼ 0.403). The mean BI score was 78.1 15.3 in patients with anxious temperament and 68.0 28.3 in patients without anxious temperament (p ¼ 0.541). Multiple linear regression analysis indicated that BI score was not associated with affective temperament changes. Conclusion: The results of the current study suggest that depressive and anxious temperaments are the most common affective temperaments and that there appears to be no association between disability level and dominant affective temperament in stroke survivors. Introduction
Affective temperament describes attitudes and behaviours that stand on structural, genetic and biological bases (1). Based on Kraepelin’s identification of four overlapping temperaments and Kretschmer’s concept of a continuum between temperament and affective disorders, Akiskal et al. (2) operationalised four types of affective temperaments: depressive, hyperthymic, cyclothymic and irritable, and an anxious type was added later. These temperaments could either be characteristic for each individual, without developing any affective illness, or constitute a predisposition pattern for an affective episode (3). Akiskal et al. (4) proposed a dimensional concept for unipolar major depression, ranging from depressive temperament to major depressive episodes and from hyperthymic, as well as cyclothymic, temperament to full-blown syndromes of bipolar affective disorders. Depression can be a comorbid or premorbid complication in stroke survivors. Premorbid depression has been identified as an independent risk factor for stroke (5–9). Post-stroke depression (PSD) is the most frequent psychiatric complication following stroke, affecting up to 50% of all such patients (10).
Erhan Kurt1, Ilhan Karacan2, Nihal Ozaras2, Gazi Alatas1 1 Department of Psychiatry, Bakirkoy Training and Research Hospital for Psychiatry and Neurology, Istanbul, Turkey; and 2Department of Physical Medicine and Rehabilitation, Vakif Gureba Training and Research Hospital, Istanbul, Turkey
Keywords: affective temperament; disability; prevalence; stroke Associate Professor Ilhan Karacan, Kartaltepe mah Ahu sk 5/9, 34730 Bakirkoy, Istanbul, Turkey. Tel: 90 212 534 6900; Fax: 90 212 6217580; E-mail: [email protected]
It is reported that a bidirectional relationship between PSD and disability may exist. Depression can be affected by physical disability, and also, comorbid depression amplifies the disability (11). However, Cassidy et al. (12) suggested that depression was not associated to functional disability following stroke. The relationship between depression and stroke/ disability is not very clear. This uncertainty may result from the episodic nature of depression. However, affective temperament is believed to be relatively stable across the individual’s life span (13). Affective temperament also forms the basis of affective disorders like depression (1,14). The aims of this study were to determine the most common dominant affective temperaments in stroke survivors and whether the temperament affects the disability.
Materials and methods Participants
From December 2006 to October 2007, 63 stroke patients (30 males, 33 females) hospitalised in our 295
Kurt et al. Department of Physical Medicine and Rehabilitation were included in this study. Inclusion criterion was diagnosis of ischaemic or intracerebral hemorrhagic stroke (first or subsequent event). Stroke was defined as a focal neurological deficit of sudden or rapid onset that persisted for .24 h. Exclusion criteria were based on the inability of the patient to reliably respond to questionnaires in the interview; this included severe dysphasia, cognitive impairment and reduced level of consciousness. Transient ischaemic attacks, subarachnoid haemorrhage, age below 18 years, concomitant disability conditions such as amputation, peripheral nerve entrapment, congestive heart failure, pulmonary disease and history of psychiatric diseases were other exclusion criteria. The mean age was 60.2 10.8 years, and the mean stroke duration was 23.8 29.7 months. Ischaemic infarction was observed in 82.5% of the patients and intracerebral haemorrhage in the remaining 17.5%. For 56 patients, this was their first stroke. Hemiplegic side was the left in 50.2% of the patients. The dominant hand, assessed through the questionnaire, was the right in 96.8% of the subjects.
Methods
The Turkish version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) scale was used to determine the dominant affective temperament. After providing informed consent, research volunteers were asked to complete the TEMPS-A. Vahip et al. (13) evaluated the validity and reliability of the Turkish version TEMPS-A scale. This scale is a self-report instrument consisting of five subscales. Its 100 constituent items inquire the subject’s whole life about traits along depressive, cyclothymic, hyperthymic, irritable and anxious lines. Individuals answer Ôyes’ or Ôno’ when considering their life experience. Cut-off scores to determine dominant temperament are 13 for depressive mood (19 items), 18 for cyclothymic (19 items), 20 for hyperthymic (20 items), 13 for irritable (18 items) and 18 for anxious (24 items) mood. It is possible to have more than one dominant affective temperament. The physical disability was measured through the Barthel index (BI). The BI was administered after the TEMPS-A scale. This index includes feeding, moving from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing, walking on level surface, going up and down stairs, dressing and continence of bowels and bladder (14). 296
BI is a valid measure of disability. It consists of 10 items that measure an individual’s daily functioning, specifically the activities of daily living and mobility. A potential maximum score is 100. The higher the score, the more Ôindependent’ the individual is. Independence means no assistance needs at any feature of the task. The degree of physical dependency is classified through the BI total score (0–20: complete dependent, 21–61: severe dependent, 62–90: moderate dependent, 91–99: mild dependent, 100: complete independent) (13). In this study, two disability levels were defined: complete or severe physical dependency was accepted as a high-level disability; complete physical independency, moderate physical dependency or mild physical dependency was accepted as a low-level disability. Brunnstrom Motor Recovery Stages is an impairment scale that was used to determine the subjects’ hemiparesis severity (15). It was administered after the TEMPS-A scale. Table 1 details the assessment of Brunnstrom stages. Statistical analysis
Mean, standard deviation and 95% confidence intervals (CIs) were calculated for each variable assessed. The Mann-Whitney U test was used to analyse the statistical difference between the TEMPS-A subscale scores of the patients with low- and high-level disabilities. This test was also used to analyse the statistical difference in the BI scores between the patients with and without the dominant affective temperament. Chi-squared and Fisher’s exact tests were performed to analyse the distribution of the dominant affective temperaments. Odds ratios and 95% CI were calculated for stroke risk. The multiple linear regression analysis (method: enter) was used to identify predictors of the BI score in relation to the demographic and clinical findings [age, gender, body mass index (BMI), stroke duration, dominant affective temperaments Table 1. Brunnstrom stages of motor recovery Stage 1 2 3 4 5 6
Characteristics No activation of the limb Spasticity appears, and weak basic flexor and extensor synergies are present Spasticity is prominent; the patient voluntarily moves the limb, but muscle activation is all within the synergy patterns The patient begins to activate muscles selectively outside the flexor and extensor synergies Spasticity decreases; most muscle activation is selective and independent from the limb synergies Isolated movements are performed in a smooth, phasic, well-coordinated manner
Affective temperament in stroke and Brunnstrom stage]. Validity of the final regression model was determined by analysis of variance. A p value less than 0.05 was considered statistically significant. The data management software package used was the Statistical Package for the Social Sciences version 10.0 for Windows
Table 3. Association between depressive temperament and side of hemisphere damage
Depressive temperament 2 1 Total number
Left-hemisphere damage, n (%)
Right-hemisphere damage, n (%)
27 (87.1) 4 (12.9) 31 (100)
25 (78.1) 7 (21.9) 32 (100)
p Value 0.509
Results
The most common Brunnstrom stage was stage 3 (25.4%). The mean BI score was 69.2 27.1. Of all patients, 20 (31.7%) had a high level of disability. Depressive (17.5%) and anxious (12.7%) temperaments were the most common dominant affective temperaments, whereas the irritable (4.8%), cyclothymic (3.2%) and hyperthymic (0%) temperaments were relatively uncommon (chi-square 18.67, p ¼ 0.0009). Three patients had both depressive and anxious temperaments; one had both depressive and cyclothymic temperaments and one had depressive, anxious and irritable temperaments. There was no significant difference in the TEMPS-A subscale scores between patients with high- and lowlevel disabilities (Table 2). Among the 11 subjects detected with depressive temperament, 7 had left-hemisphere damage. There was not an association between depressive temperament and side of hemisphere damage (Fisher’s exact test, p ¼ 0.509) (Table 3). The most common degree of physical dependency was moderate in all dominant temperament groups (Table 4). The mean BI score was 78.1 18.3 in patients with depressive temperament and 67.4 28.4 in patients without depressive temperament (p ¼ 0.403). The mean BI score was 78.1 15.3 in patients with anxious temperament and 68.0 28.3 in patients without anxious temperament (p ¼ 0.541) (Table 5).
Table 2. Scores of the subscales of TEMPS-A in patients with high- or low-level disability Subscales of TEMPS-A Depressive Cyclothymic Hyperthymic Irritable Anxious
Disability level
n
High Low High Low High Low High Low High Low
20 43 20 43 20 43 20 43 20 43
BI score 9.3 9.7 9.1 9.5 10.3 10.6 5.0 5.9 9.1 8.4
3.5 3.9 3.3 5.4 4.4 4.6 3.7 4.6 5.2 6.9
95% CI 2.4 2.0 2.6 21.0 1.6 1.5 22.2 23.1 21.0 25.1
to to to to to to to to to to
16.1 17.3 15.5 20.0 18.9 19.6 12.2 14.9 19.2 21.9
p Value 0.609 0.625 0.900 0.651 0.371
Multiple linear regression analysis indicated that the BI score was not associated with gender, stroke duration, depressive temperament, anxious temperament, cyclothymic temperament or irritable temperament. Contrarily, it also revealed that the BI score was associated with age, BMI and Brunnstrom stage (R2 ¼ 0.686, F ¼ 12.8, p ¼ 0.0001) (Table 6).
Discussion
This is the first study evaluating the affective temperament of stroke survivors. We found that depressive and anxious temperaments were the most common dominant affective temperaments and that the dominant affective temperament did not have an effect on disability in stroke patients. The validity and reliability of TEMPS-A were proved in many languages, including Turkish (13). In this study, it was found that depressive (17.5%) and anxious (12.7%) temperaments were the most common in stroke survivors. Vahip et al. (13) found that dominant irritable (3.7%), anxious (3.7%) and depressive (3.1%) temperaments were the most common in 658 healthy Turkish subjects, whereas dominant cyclothymic (1.7%) and hyperthymic (1.2%) temperaments were relatively uncommon. The depressive and anxious temperaments appeared to be more common in our stroke patients than in normal Turkish population. Vahip et al. reported that 1.2% of their sample consisting of 658 non-clinical subjects presented hyperthymic temperament. The present sample comprised 63 stroke patients. Because of this small size, hyperthymic temperaments could not be detected in any of this study’s participants. When the prevalence from this study group was compared to the corresponding prevalence from the healthy Turkish population, it was found that the risk for stroke was higher in subjects with than in those without depressive temperament (odds ratio ¼ 6.75, 95% CI: 2.85–15.78) and in subjects with than in those without anxious temperament (odds ratio ¼ 3.84, 95% CI: 1.51–9.52). Depression has been identified as an independent stroke risk factor (5). This high risk for stroke in subjects with depressive temperament is consistent with the high 297
Kurt et al. Table 4. Association between physical dependency and dominant affective temperament Dominant affective temperament (%) Degree of physical dependency
Disability level
Complete dependent Severe dependent Moderate dependent Mild dependent Complete independent
High
Indefinable (n ¼ 45)
Depressive (n ¼ 11)
Cyclothymic (n ¼ 2)
Irritable (n ¼ 3)
Anxious (n ¼ 8)
11.1 28.9 40.0 4.4 15.6
0 18.2 54.5 9.1 18.2
0 0 50 0 50
0 0 100 0 0
0 12.5 75 0 12.5
Low
risk for stroke in subjects with depression. Affective temperament constitutes the basis of affective disorders like depression (1,16). It was also shown that depressive temperament is related to the typical depression (17). In this study, depressive temperament was not associated with higher risk for stroke in the lefthemisphere damage compared to the right hemisphere. Depressive temperament forms the basis of depression (17). Depression, according to a number of publications (18,19), is related to organic lesions in the left hemisphere, although this relationship is controversial (20–22). Starkstein et al. provided an interesting insight into the association between depression and cerebral lesion location. They showed that the association between depression and lesion location was restricted to patients with a typical occipital asymmetry and was not present in patients with a reversed occipital asymmetry (22). It should be investigated whether there is a similar association between depressive temperament and location of the brain lesion. Several clinical factors have been identified as potential predictors of disability level such as age, gender, marital status, educational level, stroke history, degree of motor impairment and comorbidities (23,24). The physical disability may be measured through several scale types, such as Functional Independence Measure, BI, Rehabilitation Institute of Chicago Functional Assessment Scale (25). We preferred to use the BI and applied it to our stroke patients after the TEMPS-A scale. The physical Table 5. The BI score in patients with and without the affective temperament Dominant temperament The stroke patients
298
With Without With Without With Without With Without
Depressive Anxious Cyclothymic Irritable
n 11 52 8 55 2 61 3 60
BI score
95% CI
p Value
43.3–112.8 13.4–121.3 49.0–107.1 14.2–121.7 63.2–116.7 16.7–120.4 77.9–88.6 16.0–120.9
0.403
78.1 67.4 78.1 68.0 90.0 68.6 83.3 68.5
18.3 28.4 15.3 28.3 14.1 27.3 2.8 27.6
0.541 0.245 0.436
disability was associated with age, BMI and Brunnstrom stage, whereas no association between the dominant affective temperament and the disability was determined. Although this study shows that the dominant affective temperament and the current disability level are not involved, it is possible that affective temperament may influence the recovery degree of physical disability over time. For this reason, by this present study, it cannot be claimed that there is no absolute effect of the dominant affective temperament on the disability level of stroke survivors. There are several limitations in the current study. First, despite reminding every individual filling the questionnaire to take their whole lives into consideration, there might have been some difficulties on their part regarding premorbid personality evaluation. We tried to overcome this limitation by excluding individuals unable to reliably respond to interview questionnaires. Second, there was a probability that the existent cerebral lesion could have affected the temperament. We did not know whether the premorbid temperament of our patients had changed or not following the cerebrovascular accident. A longitudinal study could further provide more definite and reliable information regarding these questions. Third, the number of cases included in Table 6. The regression model for BI score
Model Constant Age Gender (female) BMI Brunnstrom stage Duration of stroke Depressive temperament Anxious temperament Cyclothymic temperament Irritable temperament
B
Standard error Beta
33.11 20.63 28.93 1.30 11.80 0.11 6.45
20.03 0.20 4.54 0.45 1.50 0.07 6.10
0.84
7.05
29.50
14.33
7.59
10.83
t
1.65 20.25 23.18 20.16 21.96 0.22 2.83 0.66 7.84 0.12 1.52 0.09 1.05
p Value
95% CI for B
0.104 0.002 0.055 0.007 0.000 0.134 0.295
27.06 21.04 218.04 0.38 8.78 20.03 25.79
0.11
0.905
213.30 to 14.98
20.06 20.66
0.510
238.26 to 19.24
0.486
214.13 to 29.32
0.01
0.06
0.70
to to to to to to to
73.29 20.23 0.18 2.22 14.82 0.26 18.69
Affective temperament in stroke this study was relatively small. The total number of patients having dominant affective temperament was 18 (28.5%). Multiple linear regression analysis could have been more reliable if the number of stroke patients had been higher. The results of the current study suggest that depressive and anxious temperaments are the most common affective temperaments, and there appears to be no association between the disability level and the dominant affective temperament in stroke survivors.
Acknowledgements The authors thank Dr Simavi Vahip for his suggestions during the design of this study’s methodology.
References 1. GOODWIN FK, JAMISON KR. Manic-depressive illness. New York: Oxford University Press, 1990. 2. AKISKAL HS, PLACIDI GF, MAREMMANI I et al. TEMPS-I: delineating the most discriminant traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population. J Affect Disord 1998;51:7–19. 3. VA´ZQUEZ GH, KAHN C, SCHIAVO CE et al. Bipolar disorders and affective temperaments: a national family study testing the ‘‘endophenotype’’ and ‘‘subaffective’’ theses using the TEMPS-A Buenos Aires. J Affect Disord 2008;108:25–32. 4. AKISKAL HS, BRIEGER P, MUNDT C, ANGST J, MARNEROS A. Temperament und affektive Storungen. Die TEMPSA-Skala als Konvergenz europaischer und US-amerikanischer Konzepte, Temperament and affective disorders. The TEMPS-A Scale as a convergence of European and US-American concepts. Nervenarzt 2002;73:262–271. 5. WILLIAMS LS. Depression, stroke: cause or consequence? Semin Neurol 2005;25:396–409. 6. SALAYCIK KJ, KELLY-HAYES M, BEISER A et al. Depressive symptoms and risk of stroke: the Framingham Study. Stroke 2007;38:16–21. Epub 2006 Nov 30. 7. SCHMITZ N, WANG J, MALLA A, LESAGE A. Joint effect of depression and chronic conditions on disability: results from a population-based study. Psychosom Med 2007;69:332–338. Epub 2007 Apr 30. 8. VAN DE PORT IG, KWAKKEL G, BRUIN M, LINDEMAN E. Determinants of depression in chronic stroke: a prospective cohort study. Disabil Rehabil 2007;29:353–358. 9. APRILE I, PIAZZINI DB, BERTOLINI C et al. Predictive variables on disability and quality of life in stroke outpatients undergoing rehabilitation. Neurol Sci 2006;27:40–46.
10. KRONENBERG G, KATCHANOV J, ENDRES M. Post-stroke depression. Clinical aspects, epidemiology, therapy, and pathophysiology. Nervenarzt 2006;77:1176, 1179–1182, 1184–1185. 11. MORRISON V, POLLARD B, JOHNSTON M, MACWALTER R. Anxiety and depression 3 years following stroke: demographic, clinical, and psychological predictors. J Psychosom Res 2005;59:209–213. 12. CASSIDY E, O’CONNOR R, O’KEANE V. Prevalence of poststroke depression in an Irish sample and its relationship with disability and outcome following inpatient rehabilitation. Disabil Rehabil 2004;26:71–77. 13. VAHIP S, KESEBIR S, ALKAN M, YAZICI O, AKISKAL KK, AKISKAL HS. Affective temperaments in clinically-well subjects in Turkey: initial psychometric data on the TEMPS-A. J Affect Disord 2005;85:113–125. 14. MAHONEY FI, BARTHEL D. Functional evaluation: the Barthel Index. Md State Med J 1965;14:56–61. Used with permission. 15. BRUNNSTROM S. Movement therapy in hemiplegia: a neurophysiological Approach. Philadelphia: Harper and Row, 1970. 16. KESEBIR S, VAHIP S, AKDENIZ F, YU¨NCU¨ Z. The relationship of affective temperament and clinical features in bipolar disorder. Turk Psikiyatri Derg 2005;16:164–169. 17. AKDENIZ F, KESEBIR S, VAHIP S, GO¨NU¨L AS. Is there a relationship between mood disorders and affective temperaments? Turk Psikiyatri Derg 2004;15:183–190. 18. BARKER-COLLO SL. Depression and anxiety 3 months post stroke: prevalence and correlates. Arch Clin Neuropsychol 2007;22:519–531. 19. MORRIS PL, ROBINSON RG, RAPHAEL B. Prevalence and course of depressive disorders in hospitalized stroke patients. Int J Psychiatry Med 1990;20:349–364. 20. IACOBONI M, PADOVANI A, DI PIERO V, LENZI GL. Poststroke depression: relationships with morphological damage and cognition over time. Ital J Neurol Sci. 1995;16: 209–216. 21. SINYOR D, AMATO P, KALOUPEK DG, BECKER R, GOLDENBERG M, COOPERSMITH H. Post-stroke depression: relationships to functional impairment, coping strategies, and rehabilitation outcome. Stroke 1986;17:1102–1107. 22. STARKSTEIN SE, BRYER JB, BERTHIER ML, COHEN B, PRICE TR, ROBINSON RG. Depression after stroke: the importance of cerebral hemisphere asymmetries. J Neuropsychiatry Clin Neurosci 1991;3:276–285. 23. CHAE J, JOHNSTON M, KIM H, ZOROWITZ R. Admission motor impairment as a predictor of physical disability after stroke rehabilitation. Am J Phys Med Rehabil 1995;74: 218–223. 24. LIU X, LV Y, WANG B, ZHAO G, YAN Y, XU D. Prediction of functional outcome of ischemic stroke patients in northwest China. Clin Neurol Neurosurg 2007;109:571–577. 25. FRATTALI CM. Outcome measurements: definitions, dimensions, and perspectives. In: Frattali CM, ed. Measuring outcomes in speech-language pathology. New York: Thieme, 1998:6.
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Acta Neuropsychiatrica 2008: 20: 295–299 All rights reserved DOI: 10.1111/j.1601-5215.2008.00335.x
ACTA NEUROPSYCHIATRICA
Affective temperament in stroke patients Kurt E, Karacan I, Ozaras N, Alatas G. Affective temperament in stroke patients. Objective: The aims of this study were to determine the dominant affective temperament changes in stroke survivors and whether temperament affects the disability. Methods: A total of 63 stroke patients were included in this study. Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire was used to determine the dominant affective temperament (depressive, hyperthymic, cyclothymic, irritable or anxious). The disability level was measured with the Barthel index (BI). Results: Depressive temperament (17.5%) and anxious temperament (12.7%) were the most common dominant affective temperaments. The frequencies of irritable, cyclothymic and hyperthymic temperaments were 4.8, 3.2 and 0%, respectively. The mean BI score was 78.1 18.3 in patients with depressive temperament and 67.4 28.4 in patients without depressive temperament (p ¼ 0.403). The mean BI score was 78.1 15.3 in patients with anxious temperament and 68.0 28.3 in patients without anxious temperament (p ¼ 0.541). Multiple linear regression analysis indicated that BI score was not associated with affective temperament changes. Conclusion: The results of the current study suggest that depressive and anxious temperaments are the most common affective temperaments and that there appears to be no association between disability level and dominant affective temperament in stroke survivors. Introduction
Affective temperament describes attitudes and behaviours that stand on structural, genetic and biological bases (1). Based on Kraepelin’s identification of four overlapping temperaments and Kretschmer’s concept of a continuum between temperament and affective disorders, Akiskal et al. (2) operationalised four types of affective temperaments: depressive, hyperthymic, cyclothymic and irritable, and an anxious type was added later. These temperaments could either be characteristic for each individual, without developing any affective illness, or constitute a predisposition pattern for an affective episode (3). Akiskal et al. (4) proposed a dimensional concept for unipolar major depression, ranging from depressive temperament to major depressive episodes and from hyperthymic, as well as cyclothymic, temperament to full-blown syndromes of bipolar affective disorders. Depression can be a comorbid or premorbid complication in stroke survivors. Premorbid depression has been identified as an independent risk factor for stroke (5–9). Post-stroke depression (PSD) is the most frequent psychiatric complication following stroke, affecting up to 50% of all such patients (10).
Erhan Kurt1, Ilhan Karacan2, Nihal Ozaras2, Gazi Alatas1 1 Department of Psychiatry, Bakirkoy Training and Research Hospital for Psychiatry and Neurology, Istanbul, Turkey; and 2Department of Physical Medicine and Rehabilitation, Vakif Gureba Training and Research Hospital, Istanbul, Turkey
Keywords: affective temperament; disability; prevalence; stroke Associate Professor Ilhan Karacan, Kartaltepe mah Ahu sk 5/9, 34730 Bakirkoy, Istanbul, Turkey. Tel: 90 212 534 6900; Fax: 90 212 6217580; E-mail: [email protected]
It is reported that a bidirectional relationship between PSD and disability may exist. Depression can be affected by physical disability, and also, comorbid depression amplifies the disability (11). However, Cassidy et al. (12) suggested that depression was not associated to functional disability following stroke. The relationship between depression and stroke/ disability is not very clear. This uncertainty may result from the episodic nature of depression. However, affective temperament is believed to be relatively stable across the individual’s life span (13). Affective temperament also forms the basis of affective disorders like depression (1,14). The aims of this study were to determine the most common dominant affective temperaments in stroke survivors and whether the temperament affects the disability.
Materials and methods Participants
From December 2006 to October 2007, 63 stroke patients (30 males, 33 females) hospitalised in our 295
Kurt et al. Department of Physical Medicine and Rehabilitation were included in this study. Inclusion criterion was diagnosis of ischaemic or intracerebral hemorrhagic stroke (first or subsequent event). Stroke was defined as a focal neurological deficit of sudden or rapid onset that persisted for .24 h. Exclusion criteria were based on the inability of the patient to reliably respond to questionnaires in the interview; this included severe dysphasia, cognitive impairment and reduced level of consciousness. Transient ischaemic attacks, subarachnoid haemorrhage, age below 18 years, concomitant disability conditions such as amputation, peripheral nerve entrapment, congestive heart failure, pulmonary disease and history of psychiatric diseases were other exclusion criteria. The mean age was 60.2 10.8 years, and the mean stroke duration was 23.8 29.7 months. Ischaemic infarction was observed in 82.5% of the patients and intracerebral haemorrhage in the remaining 17.5%. For 56 patients, this was their first stroke. Hemiplegic side was the left in 50.2% of the patients. The dominant hand, assessed through the questionnaire, was the right in 96.8% of the subjects.
Methods
The Turkish version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) scale was used to determine the dominant affective temperament. After providing informed consent, research volunteers were asked to complete the TEMPS-A. Vahip et al. (13) evaluated the validity and reliability of the Turkish version TEMPS-A scale. This scale is a self-report instrument consisting of five subscales. Its 100 constituent items inquire the subject’s whole life about traits along depressive, cyclothymic, hyperthymic, irritable and anxious lines. Individuals answer Ôyes’ or Ôno’ when considering their life experience. Cut-off scores to determine dominant temperament are 13 for depressive mood (19 items), 18 for cyclothymic (19 items), 20 for hyperthymic (20 items), 13 for irritable (18 items) and 18 for anxious (24 items) mood. It is possible to have more than one dominant affective temperament. The physical disability was measured through the Barthel index (BI). The BI was administered after the TEMPS-A scale. This index includes feeding, moving from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing, walking on level surface, going up and down stairs, dressing and continence of bowels and bladder (14). 296
BI is a valid measure of disability. It consists of 10 items that measure an individual’s daily functioning, specifically the activities of daily living and mobility. A potential maximum score is 100. The higher the score, the more Ôindependent’ the individual is. Independence means no assistance needs at any feature of the task. The degree of physical dependency is classified through the BI total score (0–20: complete dependent, 21–61: severe dependent, 62–90: moderate dependent, 91–99: mild dependent, 100: complete independent) (13). In this study, two disability levels were defined: complete or severe physical dependency was accepted as a high-level disability; complete physical independency, moderate physical dependency or mild physical dependency was accepted as a low-level disability. Brunnstrom Motor Recovery Stages is an impairment scale that was used to determine the subjects’ hemiparesis severity (15). It was administered after the TEMPS-A scale. Table 1 details the assessment of Brunnstrom stages. Statistical analysis
Mean, standard deviation and 95% confidence intervals (CIs) were calculated for each variable assessed. The Mann-Whitney U test was used to analyse the statistical difference between the TEMPS-A subscale scores of the patients with low- and high-level disabilities. This test was also used to analyse the statistical difference in the BI scores between the patients with and without the dominant affective temperament. Chi-squared and Fisher’s exact tests were performed to analyse the distribution of the dominant affective temperaments. Odds ratios and 95% CI were calculated for stroke risk. The multiple linear regression analysis (method: enter) was used to identify predictors of the BI score in relation to the demographic and clinical findings [age, gender, body mass index (BMI), stroke duration, dominant affective temperaments Table 1. Brunnstrom stages of motor recovery Stage 1 2 3 4 5 6
Characteristics No activation of the limb Spasticity appears, and weak basic flexor and extensor synergies are present Spasticity is prominent; the patient voluntarily moves the limb, but muscle activation is all within the synergy patterns The patient begins to activate muscles selectively outside the flexor and extensor synergies Spasticity decreases; most muscle activation is selective and independent from the limb synergies Isolated movements are performed in a smooth, phasic, well-coordinated manner
Affective temperament in stroke and Brunnstrom stage]. Validity of the final regression model was determined by analysis of variance. A p value less than 0.05 was considered statistically significant. The data management software package used was the Statistical Package for the Social Sciences version 10.0 for Windows
Table 3. Association between depressive temperament and side of hemisphere damage
Depressive temperament 2 1 Total number
Left-hemisphere damage, n (%)
Right-hemisphere damage, n (%)
27 (87.1) 4 (12.9) 31 (100)
25 (78.1) 7 (21.9) 32 (100)
p Value 0.509
Results
The most common Brunnstrom stage was stage 3 (25.4%). The mean BI score was 69.2 27.1. Of all patients, 20 (31.7%) had a high level of disability. Depressive (17.5%) and anxious (12.7%) temperaments were the most common dominant affective temperaments, whereas the irritable (4.8%), cyclothymic (3.2%) and hyperthymic (0%) temperaments were relatively uncommon (chi-square 18.67, p ¼ 0.0009). Three patients had both depressive and anxious temperaments; one had both depressive and cyclothymic temperaments and one had depressive, anxious and irritable temperaments. There was no significant difference in the TEMPS-A subscale scores between patients with high- and lowlevel disabilities (Table 2). Among the 11 subjects detected with depressive temperament, 7 had left-hemisphere damage. There was not an association between depressive temperament and side of hemisphere damage (Fisher’s exact test, p ¼ 0.509) (Table 3). The most common degree of physical dependency was moderate in all dominant temperament groups (Table 4). The mean BI score was 78.1 18.3 in patients with depressive temperament and 67.4 28.4 in patients without depressive temperament (p ¼ 0.403). The mean BI score was 78.1 15.3 in patients with anxious temperament and 68.0 28.3 in patients without anxious temperament (p ¼ 0.541) (Table 5).
Table 2. Scores of the subscales of TEMPS-A in patients with high- or low-level disability Subscales of TEMPS-A Depressive Cyclothymic Hyperthymic Irritable Anxious
Disability level
n
High Low High Low High Low High Low High Low
20 43 20 43 20 43 20 43 20 43
BI score 9.3 9.7 9.1 9.5 10.3 10.6 5.0 5.9 9.1 8.4
3.5 3.9 3.3 5.4 4.4 4.6 3.7 4.6 5.2 6.9
95% CI 2.4 2.0 2.6 21.0 1.6 1.5 22.2 23.1 21.0 25.1
to to to to to to to to to to
16.1 17.3 15.5 20.0 18.9 19.6 12.2 14.9 19.2 21.9
p Value 0.609 0.625 0.900 0.651 0.371
Multiple linear regression analysis indicated that the BI score was not associated with gender, stroke duration, depressive temperament, anxious temperament, cyclothymic temperament or irritable temperament. Contrarily, it also revealed that the BI score was associated with age, BMI and Brunnstrom stage (R2 ¼ 0.686, F ¼ 12.8, p ¼ 0.0001) (Table 6).
Discussion
This is the first study evaluating the affective temperament of stroke survivors. We found that depressive and anxious temperaments were the most common dominant affective temperaments and that the dominant affective temperament did not have an effect on disability in stroke patients. The validity and reliability of TEMPS-A were proved in many languages, including Turkish (13). In this study, it was found that depressive (17.5%) and anxious (12.7%) temperaments were the most common in stroke survivors. Vahip et al. (13) found that dominant irritable (3.7%), anxious (3.7%) and depressive (3.1%) temperaments were the most common in 658 healthy Turkish subjects, whereas dominant cyclothymic (1.7%) and hyperthymic (1.2%) temperaments were relatively uncommon. The depressive and anxious temperaments appeared to be more common in our stroke patients than in normal Turkish population. Vahip et al. reported that 1.2% of their sample consisting of 658 non-clinical subjects presented hyperthymic temperament. The present sample comprised 63 stroke patients. Because of this small size, hyperthymic temperaments could not be detected in any of this study’s participants. When the prevalence from this study group was compared to the corresponding prevalence from the healthy Turkish population, it was found that the risk for stroke was higher in subjects with than in those without depressive temperament (odds ratio ¼ 6.75, 95% CI: 2.85–15.78) and in subjects with than in those without anxious temperament (odds ratio ¼ 3.84, 95% CI: 1.51–9.52). Depression has been identified as an independent stroke risk factor (5). This high risk for stroke in subjects with depressive temperament is consistent with the high 297
Kurt et al. Table 4. Association between physical dependency and dominant affective temperament Dominant affective temperament (%) Degree of physical dependency
Disability level
Complete dependent Severe dependent Moderate dependent Mild dependent Complete independent
High
Indefinable (n ¼ 45)
Depressive (n ¼ 11)
Cyclothymic (n ¼ 2)
Irritable (n ¼ 3)
Anxious (n ¼ 8)
11.1 28.9 40.0 4.4 15.6
0 18.2 54.5 9.1 18.2
0 0 50 0 50
0 0 100 0 0
0 12.5 75 0 12.5
Low
risk for stroke in subjects with depression. Affective temperament constitutes the basis of affective disorders like depression (1,16). It was also shown that depressive temperament is related to the typical depression (17). In this study, depressive temperament was not associated with higher risk for stroke in the lefthemisphere damage compared to the right hemisphere. Depressive temperament forms the basis of depression (17). Depression, according to a number of publications (18,19), is related to organic lesions in the left hemisphere, although this relationship is controversial (20–22). Starkstein et al. provided an interesting insight into the association between depression and cerebral lesion location. They showed that the association between depression and lesion location was restricted to patients with a typical occipital asymmetry and was not present in patients with a reversed occipital asymmetry (22). It should be investigated whether there is a similar association between depressive temperament and location of the brain lesion. Several clinical factors have been identified as potential predictors of disability level such as age, gender, marital status, educational level, stroke history, degree of motor impairment and comorbidities (23,24). The physical disability may be measured through several scale types, such as Functional Independence Measure, BI, Rehabilitation Institute of Chicago Functional Assessment Scale (25). We preferred to use the BI and applied it to our stroke patients after the TEMPS-A scale. The physical Table 5. The BI score in patients with and without the affective temperament Dominant temperament The stroke patients
298
With Without With Without With Without With Without
Depressive Anxious Cyclothymic Irritable
n 11 52 8 55 2 61 3 60
BI score
95% CI
p Value
43.3–112.8 13.4–121.3 49.0–107.1 14.2–121.7 63.2–116.7 16.7–120.4 77.9–88.6 16.0–120.9
0.403
78.1 67.4 78.1 68.0 90.0 68.6 83.3 68.5
18.3 28.4 15.3 28.3 14.1 27.3 2.8 27.6
0.541 0.245 0.436
disability was associated with age, BMI and Brunnstrom stage, whereas no association between the dominant affective temperament and the disability was determined. Although this study shows that the dominant affective temperament and the current disability level are not involved, it is possible that affective temperament may influence the recovery degree of physical disability over time. For this reason, by this present study, it cannot be claimed that there is no absolute effect of the dominant affective temperament on the disability level of stroke survivors. There are several limitations in the current study. First, despite reminding every individual filling the questionnaire to take their whole lives into consideration, there might have been some difficulties on their part regarding premorbid personality evaluation. We tried to overcome this limitation by excluding individuals unable to reliably respond to interview questionnaires. Second, there was a probability that the existent cerebral lesion could have affected the temperament. We did not know whether the premorbid temperament of our patients had changed or not following the cerebrovascular accident. A longitudinal study could further provide more definite and reliable information regarding these questions. Third, the number of cases included in Table 6. The regression model for BI score
Model Constant Age Gender (female) BMI Brunnstrom stage Duration of stroke Depressive temperament Anxious temperament Cyclothymic temperament Irritable temperament
B
Standard error Beta
33.11 20.63 28.93 1.30 11.80 0.11 6.45
20.03 0.20 4.54 0.45 1.50 0.07 6.10
0.84
7.05
29.50
14.33
7.59
10.83
t
1.65 20.25 23.18 20.16 21.96 0.22 2.83 0.66 7.84 0.12 1.52 0.09 1.05
p Value
95% CI for B
0.104 0.002 0.055 0.007 0.000 0.134 0.295
27.06 21.04 218.04 0.38 8.78 20.03 25.79
0.11
0.905
213.30 to 14.98
20.06 20.66
0.510
238.26 to 19.24
0.486
214.13 to 29.32
0.01
0.06
0.70
to to to to to to to
73.29 20.23 0.18 2.22 14.82 0.26 18.69
Affective temperament in stroke this study was relatively small. The total number of patients having dominant affective temperament was 18 (28.5%). Multiple linear regression analysis could have been more reliable if the number of stroke patients had been higher. The results of the current study suggest that depressive and anxious temperaments are the most common affective temperaments, and there appears to be no association between the disability level and the dominant affective temperament in stroke survivors.
Acknowledgements The authors thank Dr Simavi Vahip for his suggestions during the design of this study’s methodology.
References 1. GOODWIN FK, JAMISON KR. Manic-depressive illness. New York: Oxford University Press, 1990. 2. AKISKAL HS, PLACIDI GF, MAREMMANI I et al. TEMPS-I: delineating the most discriminant traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population. J Affect Disord 1998;51:7–19. 3. VA´ZQUEZ GH, KAHN C, SCHIAVO CE et al. Bipolar disorders and affective temperaments: a national family study testing the ‘‘endophenotype’’ and ‘‘subaffective’’ theses using the TEMPS-A Buenos Aires. J Affect Disord 2008;108:25–32. 4. AKISKAL HS, BRIEGER P, MUNDT C, ANGST J, MARNEROS A. Temperament und affektive Storungen. Die TEMPSA-Skala als Konvergenz europaischer und US-amerikanischer Konzepte, Temperament and affective disorders. The TEMPS-A Scale as a convergence of European and US-American concepts. Nervenarzt 2002;73:262–271. 5. WILLIAMS LS. Depression, stroke: cause or consequence? Semin Neurol 2005;25:396–409. 6. SALAYCIK KJ, KELLY-HAYES M, BEISER A et al. Depressive symptoms and risk of stroke: the Framingham Study. Stroke 2007;38:16–21. Epub 2006 Nov 30. 7. SCHMITZ N, WANG J, MALLA A, LESAGE A. Joint effect of depression and chronic conditions on disability: results from a population-based study. Psychosom Med 2007;69:332–338. Epub 2007 Apr 30. 8. VAN DE PORT IG, KWAKKEL G, BRUIN M, LINDEMAN E. Determinants of depression in chronic stroke: a prospective cohort study. Disabil Rehabil 2007;29:353–358. 9. APRILE I, PIAZZINI DB, BERTOLINI C et al. Predictive variables on disability and quality of life in stroke outpatients undergoing rehabilitation. Neurol Sci 2006;27:40–46.
10. KRONENBERG G, KATCHANOV J, ENDRES M. Post-stroke depression. Clinical aspects, epidemiology, therapy, and pathophysiology. Nervenarzt 2006;77:1176, 1179–1182, 1184–1185. 11. MORRISON V, POLLARD B, JOHNSTON M, MACWALTER R. Anxiety and depression 3 years following stroke: demographic, clinical, and psychological predictors. J Psychosom Res 2005;59:209–213. 12. CASSIDY E, O’CONNOR R, O’KEANE V. Prevalence of poststroke depression in an Irish sample and its relationship with disability and outcome following inpatient rehabilitation. Disabil Rehabil 2004;26:71–77. 13. VAHIP S, KESEBIR S, ALKAN M, YAZICI O, AKISKAL KK, AKISKAL HS. Affective temperaments in clinically-well subjects in Turkey: initial psychometric data on the TEMPS-A. J Affect Disord 2005;85:113–125. 14. MAHONEY FI, BARTHEL D. Functional evaluation: the Barthel Index. Md State Med J 1965;14:56–61. Used with permission. 15. BRUNNSTROM S. Movement therapy in hemiplegia: a neurophysiological Approach. Philadelphia: Harper and Row, 1970. 16. KESEBIR S, VAHIP S, AKDENIZ F, YU¨NCU¨ Z. The relationship of affective temperament and clinical features in bipolar disorder. Turk Psikiyatri Derg 2005;16:164–169. 17. AKDENIZ F, KESEBIR S, VAHIP S, GO¨NU¨L AS. Is there a relationship between mood disorders and affective temperaments? Turk Psikiyatri Derg 2004;15:183–190. 18. BARKER-COLLO SL. Depression and anxiety 3 months post stroke: prevalence and correlates. Arch Clin Neuropsychol 2007;22:519–531. 19. MORRIS PL, ROBINSON RG, RAPHAEL B. Prevalence and course of depressive disorders in hospitalized stroke patients. Int J Psychiatry Med 1990;20:349–364. 20. IACOBONI M, PADOVANI A, DI PIERO V, LENZI GL. Poststroke depression: relationships with morphological damage and cognition over time. Ital J Neurol Sci. 1995;16: 209–216. 21. SINYOR D, AMATO P, KALOUPEK DG, BECKER R, GOLDENBERG M, COOPERSMITH H. Post-stroke depression: relationships to functional impairment, coping strategies, and rehabilitation outcome. Stroke 1986;17:1102–1107. 22. STARKSTEIN SE, BRYER JB, BERTHIER ML, COHEN B, PRICE TR, ROBINSON RG. Depression after stroke: the importance of cerebral hemisphere asymmetries. J Neuropsychiatry Clin Neurosci 1991;3:276–285. 23. CHAE J, JOHNSTON M, KIM H, ZOROWITZ R. Admission motor impairment as a predictor of physical disability after stroke rehabilitation. Am J Phys Med Rehabil 1995;74: 218–223. 24. LIU X, LV Y, WANG B, ZHAO G, YAN Y, XU D. Prediction of functional outcome of ischemic stroke patients in northwest China. Clin Neurol Neurosurg 2007;109:571–577. 25. FRATTALI CM. Outcome measurements: definitions, dimensions, and perspectives. In: Frattali CM, ed. Measuring outcomes in speech-language pathology. New York: Thieme, 1998:6.
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