http://informahealthcare.com/gye ISSN: 0951-3590 (print), 1473-0766 (electronic) Gynecol Endocrinol, 2014; 30(12): 894–898 ! 2014 Informa UK Ltd. DOI: 10.3109/09513590.2014.943722
PREGNANCY
Affective temperaments in pregnancy Esra Yazici1, Hasan Terzi2, Sukriye Bosgelmez2, Ahmet Bulent Yazici1, Selma Bozkurt Zincir3, and Ahmet Kale2 1
Department of Psychiatry, Medical Faculty, Sakarya University Training and Research Hospital, Turkey, 2Derince Training and Research Hospital, Kocaeli, Turkey, and 3Erenko¨y Training and Research Hospital, Istanbul, Turkey Abstract
Keywords
Aim: There are many studies on the mood disorders that occur during pregnancy, but no studies that question how affective temperaments, which are the antecedents of the mood disorders, are influenced by pregnancy. This study aims to examine the affective temperaments in women without any psychiatric diagnoses during the pregnancy period. Method: The study included 100 pregnant women at the third trimester of their pregnancy (pregnant group) and 75 non-pregnant women (control group). Structured Clinical Interview for DSM Axis-I Disorders (SCID-I) was used for the evaluation of psychiatric disorders; Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto-questionnaire (TEMPS-A) was used for the evaluation of affective temperaments. Results: The cyclothymic, irritable and anxious temperament scores of the pregnant women were significantly lower than that of the non-pregnant women (p50.05). Pregnancy predicted lower scores of cyclothymic, irritable and anxious temperaments. Younger age and lower levels of education were predictors of higher cyclothymic, anxious and depressive temperament scores. Younger age also predicted higher irritable temperament scores. Conclusion: The third trimester of pregnancy is associated with significantly lower affective temperament. Future studies may help to understand the biological background of the present findings.
Androgens, central nervous system, pregnancy
Introduction The current research findings show that specific affective temperament types (depressive, cyclothymic, hyperthymic, irritable and anxious) are the sub-syndromal (trait-related) manifestations and commonly the antecedents of minor and major mood disorders. Up to 20% of the population has some kind of marked affective temperament; depressive, cyclothymic, and anxious temperaments are more frequent in women, whereas hyperthymic and irritable temperaments predominate among men [1]. Molecular genetic studies show a strong involvement of the central serotonergic (depressive, cyclothymic, irritable and anxious temperaments) and dopaminergic (hyperthymic temperament) systems, suggesting that the genetic potential of major mood episodes lie in these temperaments [1]. It has been previously shown that hormonal changes could pave the way to mood disorders [2,3]. Estrogen and testosterone are known to be mood elevators [4]. In addition to other actions, estrogen increases the rate of degradation of monoamine oxidase and intraneuronal transport, both of which serve to increase serotonin availability in the synapse, and therefore to enhance mood. Fluctuation in estrogen levels is encountered in various phases and interventions related to a woman’s reproductive system, and periods of low estrogen are suggested to be associated with mood disturbances, including depression, in many women [4]. Gender differences involving the prevalence and progress of mood
Address for correspondence: Dr Esra Yazici, Department of Psychiatry, Medical Faculty, Sakarya University, Sakarya, Turkey. E-mail: [email protected]
History Received 14 January 2014 Revised 3 June 2014 Accepted 8 July 2014 Published online 25 July 2014
disorders, premenstrual dysphoric disorder and postpartum mental disorders all concern the relationship between sex hormones and mood disorders. Hormonal therapies have even started to appear in the agendum in the treatment of mood disorders [5]. Pregnancy is one of the periods that is most significantly associated with severe changes in sex hormones. The third trimester in particular is known to involve the highest levels of estrogen and progesterone [6]. Estrogen has been shown to have neuromodulator effects and its supportive effect in the treatment of depression has recently been investigated [7]. Progesterone is known to have a tranquilizing effect at higher levels; however, in some individuals it has been shown to have negative effect on mood at lower levels [8]. These hormones have interactions with the serotonergic and dopaminergic systems and may have an effect on mood disorders, but these interactions are still not well understood [8,9]. Pregnancy also remains not well understood regarding changes in levels of ovarian hormones and their interactions with mood. The pregnancy period may be protective or may be a risky period for psychiatric disorders, but this has not been adequately addressed in the literature for a number of years [10]. The recognition and treatment of mood disorders in the pregnancy process is of special importance, as it is of concern to the pregnant woman as well as to her existing family and the baby. There are many studies on the mood disorders that occur during this process, but no studies that question how affective temperaments are influenced by pregnancy. In this study, the authors assumed that affective temperaments, which are the antecedents of mood disorders, may undergo changes during pregnancy. The aim of this study is to determine if there is a difference between pregnant and non-pregnant women regarding affective temperaments.
Pregnancy, temperament
DOI: 10.3109/09513590.2014.943722
Methods This study was carried out jointly by the psychiatry and gynecology clinics in a training and research hospital in Kocaeli, Turkey. The study received an ethical approval from the government’s local ethics committee, and all participants were included in the study following written consent. An initial examination was conducted with voluntary participants, and those who were known (by personal declaration and anamnesis) to have chronic or serious physical diseases, such as multiple sclerosis, epilepsy, cancer, cerebrovascular disease, polycystic ovary syndrome or any other medical conditions that would affect the mood or intellectual capacity of the participant, were excluded. Following the consent of all of the participants, a psychiatrist examined each of them. The participants with sufficient intellectual capacity to answer the psychiatrist’s questions correctly were accepted for further examination in which they were assessed with the Structured Clinical Interview for DSM-IV Axis-I (SCID-I), a structured clinical interview that aids in diagnosing psychiatric disorders. The participants who did not have an active psychiatric disorder, such as depression, anxiety or psychosis, were included in the study. Among the participants, all of those in the third trimester of pregnancy were placed in the pregnant group; those with regular menstrual cycles were placed in the control group. The control group consisted of healthy relatives of the hospital staff. The participants who met the inclusion criteria following the initial examination and application of the SCID-I underwent TEMPS-A as an assessment of various affective temperaments. Structured Clinical Interview for DSM-IV Axis-I: SCID-I, Clinical Version The SCID-I is a semi-structured diagnostic interview chart whose Turkish translation and validity-reliability were performed by C¸orapc¸ ıog˘lu and others. It contains DSM-IV diagnoses. The SCID-I begins with a sociodemographic data guide and covers seven diagnosis groups: mood disorders, psychotic disorders, alcohol and substance-related disorders, anxiety disorders, somatoform disorders, eating disorders and adjustment disorders. It has high reliability for psychiatric disorders. It is used as a standard interview to affirm the diagnosis in clinical studies [11,12]. Turkish Form of Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto-questionnaire The Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Auto-questionnaire (TEMPS-A) was used in this study to assess the score averages of the subtypes of the affective temperaments of the participants. It was originally designed by Akiskal et al. [13] and adopted into Turkish by Vahip et al. [14]. It is a self-assessment scale, involving ‘‘true’’ or ‘‘false’’ indications that aim to take into account the entire life of the individual; it consists of five sub-dimensions that establish depressive, cyclothymic, hyperthymic, irritable and anxious temperaments. Statistical analysis In this study, comparison of continuous variables is performed with independent samples in t-test and one-way ANOVA analyses. The significance level for the tests was established at 0.05. If a significant difference was detected in an ANOVA test, post-hoc analysis was performed. A chi-square test was conducted for comparison of clusters of educational levels between pregnant and non-pregnant groups. Correlation analysis was used to determine the relationship between the linear variables. As age and level of education may influence affective
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Table 1. General data about the pregnant and the control group.
N Age (±SD) Having an occupation (N) Educational status (N) Current week of pregnancy (Mean±SD) Number of pregnancy (which pregnancy in order) (Mean)
Pregnant group
Control group
100 26.46 ± 4.38 16 Primary school: 49 High schlool: 36 University: 15 33.19 ± 4.71
75 25.73 ± 8.13 15 Primary school: 14 High schlool: 34 University: 17 No pregnancy
1.67 (1–5)
No pregnancy
Mean, mean value; SD, standard deviation.
temperaments, an additional ANCOVA model was performed including these variables as covariates and the group as the fixed factor. A linear regression analysis was used to establish the predictors of affective temperaments. Affective temperaments were established as dependent variables and probable predictors were established as independent variables in the regression model. All analyses were carried out using the SPSS statistical software, version 17.0 (Chicago, IL).
Results The study involved 100 pregnant women (pregnant group) and 75 non-pregnant women (control group). The average age of the pregnant group was 26.46 ± 4.38, while the average age of the control group was 25.73 ± 8.13; there was no significant difference between the groups (t ¼ 0.001, p40.05). Furthermore, there was no significant difference between occupational status (employed versus unemployed) and the number of living offspring between the groups (p40.05 for all). There was a significant difference between groups in education level; the number of women who had graduated from elementary school was significantly higher in the pregnant group (p50.05). The general characteristics of the participants are presented in Table 1. Comparison of the affective temperament scores of the groups The affective temperament scores of the groups were compared through independent samples t-test. The scores for depressive temperament were 5.26 ± 3.12 for the pregnant group and 5.22 ± 3.14 for the control group (t ¼ 0.07, p40.05). Cyclothymic temperament scores were 5.68 ± 4.23 for the pregnant group and 7.17 ± 4.88 for the control group (t ¼ –2.159, p50.05). Hyperthymic temperament scores were 9.26 ± 3.59 for the pregnant group and 8.40 ± 4.05 for the control group (t ¼ 1.485, p40.05). Irritable temperament scores were 2.15 ± 2.35 for the pregnant group and 3.62 ± 3.65 for the control group (t ¼ –3.246, p50.05). Anxious temperament scores were 4.69 ± 3.69 for the pregnant group and 6.26 ± 5.21 for the control group (t ¼ –2.341, p50.05). Accordingly, there was no significant difference between the depressive and hyperthymic temperament scores of the groups. However, the cyclothymic, irritable and anxious temperament scores of the pregnant women were significantly lower than those of the control group. The comparison of the scores of the pregnant and control groups is presented in Figure 1. In the correlation analysis of the pregnant group, no correlation could be determined between the pregnancy week and the affective temperament scores. There was no difference in terms of affective temperament scores between those employed and those not employed in either group (p40.05).
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Table 2. Linear regression temperament scores.
pregnant
18
anaysis for
predictors
of affective
nonpregnant
16
*
Depressive Cyclothymic Hyperthymic Anxious Irritable
*
14
Pregnancy
12 10
*
8
0.021 0.266 0.791
0.17 2.40 0.017
Age
0.213 2.682 0.008
0.45 6.19 0.00
Educational level
0.201 2.269 0.025
Having an occupation R2
6
0.098 1.252 0.212
0.203 2.691 0.008
0.238 beta 3.238 t 0.001 p
0.041 0.514 0.608
0.253 0.324 beta 3.267 4.297 t 0.001 0.000 p
0.166 2.056 0.041
0.040 0.440 0.660
0.172 0.088 beta 1.985 1.041 t 0.049 0.299 p
0.143 1.577 0.117
0.126 1.519 0.131
0.143 1.563 0.120
0.089 1.004 0.317
0.058 beta 0.676 t 0.500 p
0.061
0.219
0.039
0.106
0.156
4 2 0 depressive cyclothimic hypethimic irritable anxious temperament temperamet temperament temperament temperament
Figure 1. Comparison of affective temperament scores of pregnant and non-pregnant groups. *p50.05.
A negative correlation was determined between the age of the pregnant woman and the cyclothymic temperament scores (r: 0,265, p50.05). When the whole sample and control groups were assessed, there was a negative correlation between the age of the participant and the depressive, cyclothymic, irritable and anxious temperament scores (p50.05). When the affective temperament scores of the groups based on education level were compared in the pregnant group through a one-way ANOVA test, there was a significant difference between the cyclothymic temperament scores (F ¼ 3.312, p ¼ 0.041); the analyses found that the cyclothymic temperament scores of elementary school graduates (6.59 ± 4.11) were higher than those of high school graduates (4.27 ± 3.26) (p50.05). In the control group, there was a significant difference for cyclothymic (F ¼ 8.313, p50.05) and irritable (F ¼ 7.554, p50.05) temperaments according to education level. In a post-hoc analysis of the control group, all education groups were different from each other (elementary school, high school, university) and the highest scores belonged to high school graduates for both temperaments. There was no significant difference between the groups based on educational status for other affective temperaments (p40.05). Also, no significant difference is determined in the whole sample according to the education group (p40.05). The age and education of the participants showed a relationship with affective temperaments, and thus a covariance analysis in a general linear model was conducted to eliminate the probable effect of age and education on the difference between the groups. The analysis was conducted with age and education as covariants, group as the fixed factor, and scores of affective temperaments as dependent variables. In this model, the differences between the pregnant and control groups were still significant for cyclothymic temperament (F ¼ 5.483, adjusted R2¼0.195, p50.05), irritable temperament (F ¼ 10.524, adjusted R2 ¼ 0.141, p50.05), and anxious temperament (F ¼ 6.864, adjusted R2 ¼ 0.085, p50.05). Assessment of the predictors To establish the variables that predict the affective temperament scores in the whole sample, a linear regression model was used, in which the affective temperament scores were dependent and the pregnant/non-pregnant (group), age, educational level and occupation scores were independent variables. Based on this model, pregnancy, age and education were negative predictors of cyclothymic (R2 ¼ 0.219, p50.05) and anxious temperament scores (R2 ¼ 0.106, p50.05). Pregnancy and age were negative predictors of irritable temperament scores (R2 ¼ 0.156, p50.05). Age and education were negative
Dependent variables: depressive, cyclothymic, hyperthymic, anxious, irritable temperament scores. Italic values indicate p50.05.
predictors of depressive temperament scores (R2 ¼ 0.061, p50.05). R2 values show how much of the variance in the temperament scores was explained by this model (Table 2).
Discussion This study compared the affective temperament scores of pregnant women without any psychiatric diagnoses to those of a healthy control group of non-pregnant women. Based on the results obtained in this study, the cyclothymic, anxious and irritable temperament scores of the pregnant women were lower than those of the control group. Pregnancy was an independent predictor for lower anxious, cyclothymic and irritable temperament scores. While previous retrospective and definitive studies assert that the pregnancy period is protective in terms of mood disorders, recent studies have shown that pregnancy poses risks for recurrence and relapse in bipolar patients, particularly due to the sudden discontinuance of mood stabilizers [15,16]. A review study by Bennett et al. [17] reported that the prevalence of depression in pregnancy is similar to that of the normal population during the first trimester, while it is double that of the normal population during the second and third trimesters. Another study, conducted in the US, reported that mood disorders including depression were more frequently seen in non-pregnant women than in pregnant women [18]. Previously, in affective temperament-score studies done in the context of various medical conditions known to create vulnerability to mood disorders, such as epilepsy and adolescence, high temperament scores were established in parallel with a vulnerability to mood disorders [19,20]. A study that assessed postpartum depression reported that cyclothymic and anxious temperament could be risk factors for postpartum depression independent from psychosocial factors [21]. To the best of our knowledge, this study is the first to research the relationship between affective temperament traits and the pregnancy period. Contrary to the claim that vulnerability to mood disorders increases during pregnancy, the study found that affective temperament scores, which are considered the predictor of mood disorders in pregnancy, were lower in the pregnant group than in the control group. The present study found the cyclothymic temperament scores to be significantly lower in the pregnant women than in the control group, and that pregnancy is a negative predictor of
Pregnancy, temperament
DOI: 10.3109/09513590.2014.943722
cyclothymic temperament scores. Previous studies showed that cyclothymic temperament is a significant predictor for bipolar disorder, particularly bipolar II [1]. Recent studies have shown that cyclothymic temperament could play a major role in response to medication in mood disorders [22]; these studies have attempted to determine the importance of high cyclothymic temperament scores in other fields such alcohol addiction [23], suicidal behavior [24,25], and attention-deficit hyperactivity disorder [26]. Cyclothymic temperament progresses with fast mood changes. Cyclothymic and irritable temperaments are known to be associated with increased stress reactivity in daily life [27]. Previous studies found that irritable and anxious temperaments were precursors for mood disorders and were associated with risky behaviors, impulsivity and lower compliance with medication [27,28]. Thus, all of these temperaments appear to have traits far from the quiet mental state associated with late pregnancy. All of these temperament traits have been shown to be modulated by the serotoninergic system [1]. The serotoninergic system is highly and positively influenced by ovarian reproductive hormones [29]. Serotonin plays a key role in mood regulation and the expression of affective temperaments [1,30]. In this study, the expression of anxious, irritable and cyclothymic temperament traits during the third trimester could depend on serotonin’s interaction with hormonal changes related to late pregnancy. Pregnancy is a special period during which severe hormonal changes occur and affect the lives of the pregnant women. This study was conducted with women in the third trimester of their pregnancy. Stress responses of the hypothalamic–pituitary– adrenal axis typically decrease during late pregnancy. In this period, cortisol release is reduced in response to stressors, and changes occur in the receptors that create the stress-related response in the brain. Thus, both a physically- and mentally-quiet late pregnancy results [6]. The low affective temperament scores in our study may be representative of this mental quietness. Pregnancy is important as a period during which severe changes in ovarian hormones occur. The third trimester is the period with peak levels of estrogen and progesterone, both known to have interactions with mood [17]. Estrogen was recently investigated for its supportive effect on positive emotions and progesterone is known to act as a tranquilizer at higher levels [8]. A previous study, which researched the relationship between temperament traits and ovarian steroids, detected a relationship between temperament traits and hormonal levels [31]. This study, which was conducted by Ziomkiewicz et al. [31], suggested that high extraversion and low neuroticism in women were indicated by high levels of reproductive hormones. In our study, the low scores of temperament traits in relation to the neuroticism detected in the pregnant group of the present study could support the findings of the previous study [30]. In this study, lower scores for affective temperaments indicate a protective effect against mood disorders in the third trimester, but this study is limited to an explanation of this result without evidence of hormonal levels, biological data, brain imaging and so forth. Further studies may help to find an explanation based on biological mechanisms and to establish a protocol for evaluation of affective temperament in pregnancy. This study determined a negative correlation between age and depressive, irritable and cyclothymic temperament scores in the control group, while it determined a negative correlation only between cyclothymic temperament and age in the pregnant group. Previous studies found a relationship between affective temperament traits and age [19]. The study conducted by Preti et al. [32] found a negative correlation between depressive, anxious, and cyclothymic temperament and age, while another study showed a positive relationship between depressive temperament and age
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[33]. Mood disorders are known to have a relationship with brain function, hormonal changes, cognitive and behavioral development, and other biological correlates [1]. All of these factors are also known to relate to age. Affective temperaments, which are antecedents of mood disorders, are shown to correlate with age, as well [1]. Advancing age is known to be negatively correlated with depressive temperament in women [1,19]. Age may create biological pathways affecting affective temperaments, and the role of experience in shaping cognition and behavior should be considered. Further clarification of this matter requires more time and research. This study found a relationship between lower education levels and cyclothymic temperament. A previous study showed that cyclothymic temperament could be associated with lower educational achievement [34]. In previous studies, education levels have been shown to be related to affective temperaments [19]. A bidirectional effect may be involved in this relationship. First, the effect of education on cognitive and behavioral development is known, and cognitive and behavioral aspects of affective temperaments may be affected [27,35]. Second, in the opposite direction, an effect by affective temperament on academic success or on the degree of preference for an education-oriented lifestyle may be possible [27]. These are only speculations that remain to be proved. A larger sample size and a more detailed study is required to understand the relationship between affective temperament traits and sociodemographic variables in pregnancy. This study was carried out on pregnant women who did not have any psychiatric diagnoses. In the literature, the frequency of psychiatric relapses and recurrences have been shown to increase during pregnancy in individuals with mood disorders; however, the decrease of temperament scores in healthy pregnant women suggest that pregnancy affects individuals with psychiatric disease and healthy individuals differently. While pregnancy seems to be a calm and tranquil period rather than a stress-creating condition, the stress brought about by pregnancy may have a triggering effect or may play a major role in the mental health of individuals with disease or of individuals vulnerable to disease. As there are no other studies in the literature that assess affective temperaments in pregnant women, such comments are extremely speculative and merit further examination. This study is a cross-sectional study involving a small sample, comparing pregnant women without active psychiatric diagnoses to a healthy control group. The study’s small sample size and the fact that the associated hormone levels have not been assessed are both significant constraints on the application of this research. However, the findings are valuable, as they represent the first data of this kind in this field and its associated literature. More comprehensive and detailed research into this matter in the future would enrich the data and make it more meaningful in its field.
Conclusion Based on this study, pregnancy is seen as an independent and negative predictor for irritable, anxious and cyclothymic temperament scores, and the scores for these temperaments are lower in the third trimester of pregnancy. Younger age and lower education levels seem to be worthy of review among the associated factors.
Declaration of interest Authors declare no conflict of interest regarding this study.
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2. Yazici E, Bursalioglu FS, Aydin N, Yazici AB. Menarche, puberty and psychiatric disorders. Gynecol Endocrinol 2013;29:1055–8. 3. Fernandez-Guasti A, Fiedler JL, Herrera L, Handa RJ. Sex, stress, and mood disorders: at the intersection of adrenal and gonadal hormones. Horm Metab Res 2012;44:607–18. 4. Douma SL, Husband C, O’Donnell ME, et al. Estrogen-related mood disorders: reproductive life cycle factors. ANS Adv Nurs Sci 2005;28:364–75. 5. Studd J, Nappi RE. Reproductive depression. Gynecol Endocrinol 2012;28:42–5. 6. Brunton PJ, Russell JA, Douglas AJ. Adaptive responses of the maternal hypothalamic-pituitary-adrenal axis during pregnancy and lactation. J Neuroendocrinol 2008;20:764–76. 7. Grigoriadis S, Kennedy SH. Role of estrogen in the treatment of depression. Am J Ther 2002;9:503–9. 8. Backstrom T, Haage D, Lofgren M, et al. Paradoxical effects of GABA-A modulators may explain sex steroid induced negative mood symptoms in some persons. Neuroscience 2011;191:46–54. 9. Yazici E. Which one is fluctuating?. Hormones or emotions? Bull Clin Psychopharmacol 2014;24:21. 10. Bursalioglu FS, Aydin N, Yazici E, Yazici AB. The correlation between psychiatric disorders and women’s lives. J Clin Diagn Res 2013;7:695–9. 11. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical interview for DSM-IV clinical version (SCID-I/CV). Washington, DC: American Psychiatric Press, Inc; 1996. ¨ , Yıldız M, et al. DSM-IV Eksen-I 12. C¸orapc¸ ıog˘lu A, Aydemir O _ ¸ in Yapılandırılmı¸s Klinik Go¨ru¨s¸me. Ankara: Bozuklukları Ic Hekimler Yayın Birlig˘i; 1999. 13. Akiskal HS, Akiskal KK, Haykal RF, et al. TEMPS-A: progress towards validation of a self-rated clinical version of the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire. J Affect Disord 2005;85:3–16. 14. Vahip S, Kesebir S, Alkan M, et al. Affective temperaments in clinically-well subjects in Turkey: initial psychometric data on the TEMPS-A. J Affect Disord 2005;85:113–25. 15. Sharma V, Pope CJ. Pregnancy and bipolar disorder: a systematic review. J Clin Psychiatry 2012;73:1447–55. 16. Viguera AC, Cohen LS, Baldessarini RJ, Nonacs R. Managing bipolar disorder during pregnancy: weighing the risks and benefits. Can J Psychiatry 2002;47:426–36. 17. Bennett HA, Einarson A, Taddio A, et al. Prevalence of depression during pregnancy: systematic review. Obstet Gynecol 2004;103: 698–709. 18. Vesga-Lopez O, Blanco C, Keyes K, et al. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 2008;65:805–15. 19. Yazici E, Yazici AB, Aydin N, et al. Affective temperaments in epilepsy. BCP 2012;22:254–61. 20. Mezulis A, Simonson J, McCauley E, Vander Stoep A. The association between temperament and depressive symptoms in
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PREGNANCY
Affective temperaments in pregnancy Esra Yazici1, Hasan Terzi2, Sukriye Bosgelmez2, Ahmet Bulent Yazici1, Selma Bozkurt Zincir3, and Ahmet Kale2 1
Department of Psychiatry, Medical Faculty, Sakarya University Training and Research Hospital, Turkey, 2Derince Training and Research Hospital, Kocaeli, Turkey, and 3Erenko¨y Training and Research Hospital, Istanbul, Turkey Abstract
Keywords
Aim: There are many studies on the mood disorders that occur during pregnancy, but no studies that question how affective temperaments, which are the antecedents of the mood disorders, are influenced by pregnancy. This study aims to examine the affective temperaments in women without any psychiatric diagnoses during the pregnancy period. Method: The study included 100 pregnant women at the third trimester of their pregnancy (pregnant group) and 75 non-pregnant women (control group). Structured Clinical Interview for DSM Axis-I Disorders (SCID-I) was used for the evaluation of psychiatric disorders; Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto-questionnaire (TEMPS-A) was used for the evaluation of affective temperaments. Results: The cyclothymic, irritable and anxious temperament scores of the pregnant women were significantly lower than that of the non-pregnant women (p50.05). Pregnancy predicted lower scores of cyclothymic, irritable and anxious temperaments. Younger age and lower levels of education were predictors of higher cyclothymic, anxious and depressive temperament scores. Younger age also predicted higher irritable temperament scores. Conclusion: The third trimester of pregnancy is associated with significantly lower affective temperament. Future studies may help to understand the biological background of the present findings.
Androgens, central nervous system, pregnancy
Introduction The current research findings show that specific affective temperament types (depressive, cyclothymic, hyperthymic, irritable and anxious) are the sub-syndromal (trait-related) manifestations and commonly the antecedents of minor and major mood disorders. Up to 20% of the population has some kind of marked affective temperament; depressive, cyclothymic, and anxious temperaments are more frequent in women, whereas hyperthymic and irritable temperaments predominate among men [1]. Molecular genetic studies show a strong involvement of the central serotonergic (depressive, cyclothymic, irritable and anxious temperaments) and dopaminergic (hyperthymic temperament) systems, suggesting that the genetic potential of major mood episodes lie in these temperaments [1]. It has been previously shown that hormonal changes could pave the way to mood disorders [2,3]. Estrogen and testosterone are known to be mood elevators [4]. In addition to other actions, estrogen increases the rate of degradation of monoamine oxidase and intraneuronal transport, both of which serve to increase serotonin availability in the synapse, and therefore to enhance mood. Fluctuation in estrogen levels is encountered in various phases and interventions related to a woman’s reproductive system, and periods of low estrogen are suggested to be associated with mood disturbances, including depression, in many women [4]. Gender differences involving the prevalence and progress of mood
Address for correspondence: Dr Esra Yazici, Department of Psychiatry, Medical Faculty, Sakarya University, Sakarya, Turkey. E-mail: [email protected]
History Received 14 January 2014 Revised 3 June 2014 Accepted 8 July 2014 Published online 25 July 2014
disorders, premenstrual dysphoric disorder and postpartum mental disorders all concern the relationship between sex hormones and mood disorders. Hormonal therapies have even started to appear in the agendum in the treatment of mood disorders [5]. Pregnancy is one of the periods that is most significantly associated with severe changes in sex hormones. The third trimester in particular is known to involve the highest levels of estrogen and progesterone [6]. Estrogen has been shown to have neuromodulator effects and its supportive effect in the treatment of depression has recently been investigated [7]. Progesterone is known to have a tranquilizing effect at higher levels; however, in some individuals it has been shown to have negative effect on mood at lower levels [8]. These hormones have interactions with the serotonergic and dopaminergic systems and may have an effect on mood disorders, but these interactions are still not well understood [8,9]. Pregnancy also remains not well understood regarding changes in levels of ovarian hormones and their interactions with mood. The pregnancy period may be protective or may be a risky period for psychiatric disorders, but this has not been adequately addressed in the literature for a number of years [10]. The recognition and treatment of mood disorders in the pregnancy process is of special importance, as it is of concern to the pregnant woman as well as to her existing family and the baby. There are many studies on the mood disorders that occur during this process, but no studies that question how affective temperaments are influenced by pregnancy. In this study, the authors assumed that affective temperaments, which are the antecedents of mood disorders, may undergo changes during pregnancy. The aim of this study is to determine if there is a difference between pregnant and non-pregnant women regarding affective temperaments.
Pregnancy, temperament
DOI: 10.3109/09513590.2014.943722
Methods This study was carried out jointly by the psychiatry and gynecology clinics in a training and research hospital in Kocaeli, Turkey. The study received an ethical approval from the government’s local ethics committee, and all participants were included in the study following written consent. An initial examination was conducted with voluntary participants, and those who were known (by personal declaration and anamnesis) to have chronic or serious physical diseases, such as multiple sclerosis, epilepsy, cancer, cerebrovascular disease, polycystic ovary syndrome or any other medical conditions that would affect the mood or intellectual capacity of the participant, were excluded. Following the consent of all of the participants, a psychiatrist examined each of them. The participants with sufficient intellectual capacity to answer the psychiatrist’s questions correctly were accepted for further examination in which they were assessed with the Structured Clinical Interview for DSM-IV Axis-I (SCID-I), a structured clinical interview that aids in diagnosing psychiatric disorders. The participants who did not have an active psychiatric disorder, such as depression, anxiety or psychosis, were included in the study. Among the participants, all of those in the third trimester of pregnancy were placed in the pregnant group; those with regular menstrual cycles were placed in the control group. The control group consisted of healthy relatives of the hospital staff. The participants who met the inclusion criteria following the initial examination and application of the SCID-I underwent TEMPS-A as an assessment of various affective temperaments. Structured Clinical Interview for DSM-IV Axis-I: SCID-I, Clinical Version The SCID-I is a semi-structured diagnostic interview chart whose Turkish translation and validity-reliability were performed by C¸orapc¸ ıog˘lu and others. It contains DSM-IV diagnoses. The SCID-I begins with a sociodemographic data guide and covers seven diagnosis groups: mood disorders, psychotic disorders, alcohol and substance-related disorders, anxiety disorders, somatoform disorders, eating disorders and adjustment disorders. It has high reliability for psychiatric disorders. It is used as a standard interview to affirm the diagnosis in clinical studies [11,12]. Turkish Form of Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto-questionnaire The Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Auto-questionnaire (TEMPS-A) was used in this study to assess the score averages of the subtypes of the affective temperaments of the participants. It was originally designed by Akiskal et al. [13] and adopted into Turkish by Vahip et al. [14]. It is a self-assessment scale, involving ‘‘true’’ or ‘‘false’’ indications that aim to take into account the entire life of the individual; it consists of five sub-dimensions that establish depressive, cyclothymic, hyperthymic, irritable and anxious temperaments. Statistical analysis In this study, comparison of continuous variables is performed with independent samples in t-test and one-way ANOVA analyses. The significance level for the tests was established at 0.05. If a significant difference was detected in an ANOVA test, post-hoc analysis was performed. A chi-square test was conducted for comparison of clusters of educational levels between pregnant and non-pregnant groups. Correlation analysis was used to determine the relationship between the linear variables. As age and level of education may influence affective
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Table 1. General data about the pregnant and the control group.
N Age (±SD) Having an occupation (N) Educational status (N) Current week of pregnancy (Mean±SD) Number of pregnancy (which pregnancy in order) (Mean)
Pregnant group
Control group
100 26.46 ± 4.38 16 Primary school: 49 High schlool: 36 University: 15 33.19 ± 4.71
75 25.73 ± 8.13 15 Primary school: 14 High schlool: 34 University: 17 No pregnancy
1.67 (1–5)
No pregnancy
Mean, mean value; SD, standard deviation.
temperaments, an additional ANCOVA model was performed including these variables as covariates and the group as the fixed factor. A linear regression analysis was used to establish the predictors of affective temperaments. Affective temperaments were established as dependent variables and probable predictors were established as independent variables in the regression model. All analyses were carried out using the SPSS statistical software, version 17.0 (Chicago, IL).
Results The study involved 100 pregnant women (pregnant group) and 75 non-pregnant women (control group). The average age of the pregnant group was 26.46 ± 4.38, while the average age of the control group was 25.73 ± 8.13; there was no significant difference between the groups (t ¼ 0.001, p40.05). Furthermore, there was no significant difference between occupational status (employed versus unemployed) and the number of living offspring between the groups (p40.05 for all). There was a significant difference between groups in education level; the number of women who had graduated from elementary school was significantly higher in the pregnant group (p50.05). The general characteristics of the participants are presented in Table 1. Comparison of the affective temperament scores of the groups The affective temperament scores of the groups were compared through independent samples t-test. The scores for depressive temperament were 5.26 ± 3.12 for the pregnant group and 5.22 ± 3.14 for the control group (t ¼ 0.07, p40.05). Cyclothymic temperament scores were 5.68 ± 4.23 for the pregnant group and 7.17 ± 4.88 for the control group (t ¼ –2.159, p50.05). Hyperthymic temperament scores were 9.26 ± 3.59 for the pregnant group and 8.40 ± 4.05 for the control group (t ¼ 1.485, p40.05). Irritable temperament scores were 2.15 ± 2.35 for the pregnant group and 3.62 ± 3.65 for the control group (t ¼ –3.246, p50.05). Anxious temperament scores were 4.69 ± 3.69 for the pregnant group and 6.26 ± 5.21 for the control group (t ¼ –2.341, p50.05). Accordingly, there was no significant difference between the depressive and hyperthymic temperament scores of the groups. However, the cyclothymic, irritable and anxious temperament scores of the pregnant women were significantly lower than those of the control group. The comparison of the scores of the pregnant and control groups is presented in Figure 1. In the correlation analysis of the pregnant group, no correlation could be determined between the pregnancy week and the affective temperament scores. There was no difference in terms of affective temperament scores between those employed and those not employed in either group (p40.05).
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Table 2. Linear regression temperament scores.
pregnant
18
anaysis for
predictors
of affective
nonpregnant
16
*
Depressive Cyclothymic Hyperthymic Anxious Irritable
*
14
Pregnancy
12 10
*
8
0.021 0.266 0.791
0.17 2.40 0.017
Age
0.213 2.682 0.008
0.45 6.19 0.00
Educational level
0.201 2.269 0.025
Having an occupation R2
6
0.098 1.252 0.212
0.203 2.691 0.008
0.238 beta 3.238 t 0.001 p
0.041 0.514 0.608
0.253 0.324 beta 3.267 4.297 t 0.001 0.000 p
0.166 2.056 0.041
0.040 0.440 0.660
0.172 0.088 beta 1.985 1.041 t 0.049 0.299 p
0.143 1.577 0.117
0.126 1.519 0.131
0.143 1.563 0.120
0.089 1.004 0.317
0.058 beta 0.676 t 0.500 p
0.061
0.219
0.039
0.106
0.156
4 2 0 depressive cyclothimic hypethimic irritable anxious temperament temperamet temperament temperament temperament
Figure 1. Comparison of affective temperament scores of pregnant and non-pregnant groups. *p50.05.
A negative correlation was determined between the age of the pregnant woman and the cyclothymic temperament scores (r: 0,265, p50.05). When the whole sample and control groups were assessed, there was a negative correlation between the age of the participant and the depressive, cyclothymic, irritable and anxious temperament scores (p50.05). When the affective temperament scores of the groups based on education level were compared in the pregnant group through a one-way ANOVA test, there was a significant difference between the cyclothymic temperament scores (F ¼ 3.312, p ¼ 0.041); the analyses found that the cyclothymic temperament scores of elementary school graduates (6.59 ± 4.11) were higher than those of high school graduates (4.27 ± 3.26) (p50.05). In the control group, there was a significant difference for cyclothymic (F ¼ 8.313, p50.05) and irritable (F ¼ 7.554, p50.05) temperaments according to education level. In a post-hoc analysis of the control group, all education groups were different from each other (elementary school, high school, university) and the highest scores belonged to high school graduates for both temperaments. There was no significant difference between the groups based on educational status for other affective temperaments (p40.05). Also, no significant difference is determined in the whole sample according to the education group (p40.05). The age and education of the participants showed a relationship with affective temperaments, and thus a covariance analysis in a general linear model was conducted to eliminate the probable effect of age and education on the difference between the groups. The analysis was conducted with age and education as covariants, group as the fixed factor, and scores of affective temperaments as dependent variables. In this model, the differences between the pregnant and control groups were still significant for cyclothymic temperament (F ¼ 5.483, adjusted R2¼0.195, p50.05), irritable temperament (F ¼ 10.524, adjusted R2 ¼ 0.141, p50.05), and anxious temperament (F ¼ 6.864, adjusted R2 ¼ 0.085, p50.05). Assessment of the predictors To establish the variables that predict the affective temperament scores in the whole sample, a linear regression model was used, in which the affective temperament scores were dependent and the pregnant/non-pregnant (group), age, educational level and occupation scores were independent variables. Based on this model, pregnancy, age and education were negative predictors of cyclothymic (R2 ¼ 0.219, p50.05) and anxious temperament scores (R2 ¼ 0.106, p50.05). Pregnancy and age were negative predictors of irritable temperament scores (R2 ¼ 0.156, p50.05). Age and education were negative
Dependent variables: depressive, cyclothymic, hyperthymic, anxious, irritable temperament scores. Italic values indicate p50.05.
predictors of depressive temperament scores (R2 ¼ 0.061, p50.05). R2 values show how much of the variance in the temperament scores was explained by this model (Table 2).
Discussion This study compared the affective temperament scores of pregnant women without any psychiatric diagnoses to those of a healthy control group of non-pregnant women. Based on the results obtained in this study, the cyclothymic, anxious and irritable temperament scores of the pregnant women were lower than those of the control group. Pregnancy was an independent predictor for lower anxious, cyclothymic and irritable temperament scores. While previous retrospective and definitive studies assert that the pregnancy period is protective in terms of mood disorders, recent studies have shown that pregnancy poses risks for recurrence and relapse in bipolar patients, particularly due to the sudden discontinuance of mood stabilizers [15,16]. A review study by Bennett et al. [17] reported that the prevalence of depression in pregnancy is similar to that of the normal population during the first trimester, while it is double that of the normal population during the second and third trimesters. Another study, conducted in the US, reported that mood disorders including depression were more frequently seen in non-pregnant women than in pregnant women [18]. Previously, in affective temperament-score studies done in the context of various medical conditions known to create vulnerability to mood disorders, such as epilepsy and adolescence, high temperament scores were established in parallel with a vulnerability to mood disorders [19,20]. A study that assessed postpartum depression reported that cyclothymic and anxious temperament could be risk factors for postpartum depression independent from psychosocial factors [21]. To the best of our knowledge, this study is the first to research the relationship between affective temperament traits and the pregnancy period. Contrary to the claim that vulnerability to mood disorders increases during pregnancy, the study found that affective temperament scores, which are considered the predictor of mood disorders in pregnancy, were lower in the pregnant group than in the control group. The present study found the cyclothymic temperament scores to be significantly lower in the pregnant women than in the control group, and that pregnancy is a negative predictor of
Pregnancy, temperament
DOI: 10.3109/09513590.2014.943722
cyclothymic temperament scores. Previous studies showed that cyclothymic temperament is a significant predictor for bipolar disorder, particularly bipolar II [1]. Recent studies have shown that cyclothymic temperament could play a major role in response to medication in mood disorders [22]; these studies have attempted to determine the importance of high cyclothymic temperament scores in other fields such alcohol addiction [23], suicidal behavior [24,25], and attention-deficit hyperactivity disorder [26]. Cyclothymic temperament progresses with fast mood changes. Cyclothymic and irritable temperaments are known to be associated with increased stress reactivity in daily life [27]. Previous studies found that irritable and anxious temperaments were precursors for mood disorders and were associated with risky behaviors, impulsivity and lower compliance with medication [27,28]. Thus, all of these temperaments appear to have traits far from the quiet mental state associated with late pregnancy. All of these temperament traits have been shown to be modulated by the serotoninergic system [1]. The serotoninergic system is highly and positively influenced by ovarian reproductive hormones [29]. Serotonin plays a key role in mood regulation and the expression of affective temperaments [1,30]. In this study, the expression of anxious, irritable and cyclothymic temperament traits during the third trimester could depend on serotonin’s interaction with hormonal changes related to late pregnancy. Pregnancy is a special period during which severe hormonal changes occur and affect the lives of the pregnant women. This study was conducted with women in the third trimester of their pregnancy. Stress responses of the hypothalamic–pituitary– adrenal axis typically decrease during late pregnancy. In this period, cortisol release is reduced in response to stressors, and changes occur in the receptors that create the stress-related response in the brain. Thus, both a physically- and mentally-quiet late pregnancy results [6]. The low affective temperament scores in our study may be representative of this mental quietness. Pregnancy is important as a period during which severe changes in ovarian hormones occur. The third trimester is the period with peak levels of estrogen and progesterone, both known to have interactions with mood [17]. Estrogen was recently investigated for its supportive effect on positive emotions and progesterone is known to act as a tranquilizer at higher levels [8]. A previous study, which researched the relationship between temperament traits and ovarian steroids, detected a relationship between temperament traits and hormonal levels [31]. This study, which was conducted by Ziomkiewicz et al. [31], suggested that high extraversion and low neuroticism in women were indicated by high levels of reproductive hormones. In our study, the low scores of temperament traits in relation to the neuroticism detected in the pregnant group of the present study could support the findings of the previous study [30]. In this study, lower scores for affective temperaments indicate a protective effect against mood disorders in the third trimester, but this study is limited to an explanation of this result without evidence of hormonal levels, biological data, brain imaging and so forth. Further studies may help to find an explanation based on biological mechanisms and to establish a protocol for evaluation of affective temperament in pregnancy. This study determined a negative correlation between age and depressive, irritable and cyclothymic temperament scores in the control group, while it determined a negative correlation only between cyclothymic temperament and age in the pregnant group. Previous studies found a relationship between affective temperament traits and age [19]. The study conducted by Preti et al. [32] found a negative correlation between depressive, anxious, and cyclothymic temperament and age, while another study showed a positive relationship between depressive temperament and age
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[33]. Mood disorders are known to have a relationship with brain function, hormonal changes, cognitive and behavioral development, and other biological correlates [1]. All of these factors are also known to relate to age. Affective temperaments, which are antecedents of mood disorders, are shown to correlate with age, as well [1]. Advancing age is known to be negatively correlated with depressive temperament in women [1,19]. Age may create biological pathways affecting affective temperaments, and the role of experience in shaping cognition and behavior should be considered. Further clarification of this matter requires more time and research. This study found a relationship between lower education levels and cyclothymic temperament. A previous study showed that cyclothymic temperament could be associated with lower educational achievement [34]. In previous studies, education levels have been shown to be related to affective temperaments [19]. A bidirectional effect may be involved in this relationship. First, the effect of education on cognitive and behavioral development is known, and cognitive and behavioral aspects of affective temperaments may be affected [27,35]. Second, in the opposite direction, an effect by affective temperament on academic success or on the degree of preference for an education-oriented lifestyle may be possible [27]. These are only speculations that remain to be proved. A larger sample size and a more detailed study is required to understand the relationship between affective temperament traits and sociodemographic variables in pregnancy. This study was carried out on pregnant women who did not have any psychiatric diagnoses. In the literature, the frequency of psychiatric relapses and recurrences have been shown to increase during pregnancy in individuals with mood disorders; however, the decrease of temperament scores in healthy pregnant women suggest that pregnancy affects individuals with psychiatric disease and healthy individuals differently. While pregnancy seems to be a calm and tranquil period rather than a stress-creating condition, the stress brought about by pregnancy may have a triggering effect or may play a major role in the mental health of individuals with disease or of individuals vulnerable to disease. As there are no other studies in the literature that assess affective temperaments in pregnant women, such comments are extremely speculative and merit further examination. This study is a cross-sectional study involving a small sample, comparing pregnant women without active psychiatric diagnoses to a healthy control group. The study’s small sample size and the fact that the associated hormone levels have not been assessed are both significant constraints on the application of this research. However, the findings are valuable, as they represent the first data of this kind in this field and its associated literature. More comprehensive and detailed research into this matter in the future would enrich the data and make it more meaningful in its field.
Conclusion Based on this study, pregnancy is seen as an independent and negative predictor for irritable, anxious and cyclothymic temperament scores, and the scores for these temperaments are lower in the third trimester of pregnancy. Younger age and lower education levels seem to be worthy of review among the associated factors.
Declaration of interest Authors declare no conflict of interest regarding this study.
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