ORIGINAL ARTICLE
Personality Traits of Patients With Multiple Sclerosis and Their Relationship With Clinical Characteristics Sibel Gazioglu, MD,* Vildan Altunayoglu Cakmak, MD,* Evrim Ozkorumak, MD,Þ Nuray Can Usta, MD,* Can Ates, MSc,þ and Cavit Boz, MD* Abstract: Few studies have investigated personality characteristics in people with multiple sclerosis (MS), and little is known about the relationship between personality and clinical characteristics in these patients. We aimed to investigate the personality traits of MS patients and their relationship with clinical characteristics. The study population consisted of 74 MS patients and age-matched, sex-matched, and education levelYmatched healthy controls. All participants were instructed to complete the self-administered 240-item Temperament and Character Inventory and the Beck Depression Inventory. The MS patients exhibited higher harm avoidance (HA) and lower self-directedness scores than the control group, although these differences disappeared after controlling for depression. Duration of the disease was positively correlated with HA and negatively correlated with novelty-seeking scores. Expanded Disability Status Scale scores were negatively correlated with reward dependence. Our results suggest a possible relationship between personality characteristics and the stage of the disease or the degree of damage in MS patients. Key Words: Multiple sclerosis, personality, temperament, character (J Nerv Ment Dis 2014;202: 408Y411)
M
ultiple sclerosis (MS) is a chronic demyelinating disease of the CNS that can lead to serious disability and impairs the quality of life. In addition to progressive neurological disability, neuropsychiatric symptoms and personality changes have also been reported in MS patients (Paparrigopoulos et al., 2010; Stathopoulou et al., 2010). Personality is a composite of individual behavioral, mental, and emotional response patterns. There are a number of models that assess personality traits and explain underlying biological interactions. Cloninger described a dimensional psychobiological model of personality that investigates seven personality traits referring to temperament and character. The Temperament and Character Inventory (TCI) was developed to assess the dimensions of personality. According to Cloninger’s model, dimensions of temperament consist of novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence (P), and dimensions of character consist of self-directedness (SD), cooperativeness (C), and self-transcendence (ST). Temperament dimensions constitute the heritable part of personality, with a genetic component ranging from 40% to 60%, and have been shown to be correlated with specific neurotransmitter system activities, such as dopamine, serotonin, and noradrenalin. Character dimensions are the external aspect of personality and are determined more environmentally, with a low genetic component ranging from 10% to 15% (Cloninger, 1987, 1994; Cloninger et al., 1993).
Departments of *Neurology, and †Psychiatry, Medical Faculty, Karadeniz Technical University, Trabzon, Turkey; and ‡Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey. Send reprint requests to Sibel Gazioglu, MD, Department of Neurology, Medical Faculty, Karadeniz Technical University, 61080 Trabzon, Turkey. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20205Y0408 DOI: 10.1097/NMD.0000000000000114
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Personality characteristics in MS patients have been evaluated using different instruments in previous studies (Benedict et al., 2001; Bruce and Lynch, 2011; Christodoulou et al., 1999; Fazekas et al., 2013; Gioia et al., 2009; Johnson et al., 1996; Merkelbach et al., 2003; Ozura et al., 2010; Penner et al., 2007; Ra¨tsep et al., 2000). Dimensional evaluation of personality using the TCI provides a systematic and comprehensive approach and has the advantage of evaluating personality profiles that do not always mean a personality disorder (Cloninger et al., 1993; Svrakic et al., 1993). The aims of this study were to determine the temperament and character profiles of MS patients and to investigate their relationship with clinical characteristics, such as disease duration and severity.
METHODS Subjects Seventy-four patients with definite MS according to the McDonald criteria were recruited from our MS outpatient clinic (Polman et al., 2005). Patients older than 18 years with at least primary school education and a diagnosis of MS for at least 1 year were included. Patients with mental and social retardation to understand the tests; with a diagnosis of a psychotic disorder that might interfere with clinical interview; with concurrent medical conditions such as cardiac, hepatic, renal, blood, or circulatory disorders; and with MS exacerbation or receiving corticosteroids within the preceding 3 months were excluded. Seventy-four age-matched, sex-matched, and education levelY matched control subjects were chosen at random from hospital staff, students at the medical school, and the general population by face-to-face interview. All participants underwent a detailed medical examination, including medical history, full neurological examinations, and a psychiatric interview. The duration of the disease according to the reported date of diagnosis and confirmed from the medical records and type of MS were recorded. The Kurtzke Expanded Disability Status Scale (EDSS) scale was used to measure disability (Kurtzke, 1983). All participants were instructed to complete the questionnaires, including the TCI and the Beck Depression Inventory (BDI), in a quiet room. The ethical committee approved the study, and informed consent was obtained from each subject.
Measures Temperament and Character Inventory Personality was assessed using a self-administered TCI questionnaire consisting of 240 true-false items. The TCI assesses four temperament (NS, HA, RD, and P) and three character (SD, C, and ST) dimensions of personality. The validity and reliability of the Turkish version of the TCI were reported in a recent study (Kose et al., 2004). NS reflects a heritable tendency toward behavioral activation for innovation, active avoidance of punishment or disappointment, and exaggeration in the approach to cues for potential rewards. NS includes four subdimensions: NS1, exploratory excitability versus stoic rigidity; NS2, impulsiveness versus reflection; NS3, extravagance versus reserve; and NS4, disorderliness versus regimentation. Low NS corresponds to being slow tempered, reflective, uninquiring, and tolerant of monotonous states. High NS corresponds to excitement and
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enthusiastic exploration of novel stimuli, while having the disadvantages of impulsivity, becoming bored quickly, and inattention to detail. HA reflects a heritable tendency toward behavioral inhibition to avoid nonrewarding or negative stimuli and punishment. HA consists of four subdimensions: HA1, anticipatory worry and pessimism versus uninhibited optimism; HA2, fear or uncertainty versus confidence; HA3, shyness with strangers versus gregariousness; and HA4, fatigability and asthenia versus vigor. High HA corresponds to shyness, fear of uncertainty, and easy fatigability that leads to social inhibition and anxiety. Low HA corresponds to being relaxed, energetic, courageous, and optimistic and has the disadvantages of excessive optimism and inappropriate responses even in serious danger. RD reflects a heritable tendency toward intense response to signals of social rewards and maintenance of behavior previously associated with rewards. RD includes three subdimensions: RD1, sentimentality versus insensitivity; RD3, attachment versus detachment; and RD4, dependence versus independence. High reward-dependent individuals are described as sentimental and socially sensitive, although excessive social attachment and dependence on the approval of others may influence their objectivity. Low reward-dependent individuals are described as tough minded, cool, socially insensitive, and independent. P reflects a heritable tendency toward maintenance of behavior as resistance to frustration. High P corresponds to perseverance, ambition, diligence, and perfectionism. In contrast, individuals with low P are described as inactive, indolent, and unstable. SD is the first dimension of character and the major determinant of the presence of personality disorder. SD reflects the ability to regulate and adapt behavior according to the situation to achieve individually chosen goals and values. SD has five subdimensions: SD1, responsibility versus blaming; SD2, purposefulness versus lack of goal or direction; SD3, resourcefulness versus inertia; SD4, self-acceptance versus self-striving; and SD5, congruent second nature versus incongruent habits. Individuals with high SD are described as mature, self-sufficient, and reliable with high respect and confidence. Individuals with low SD, on the other hand, are described as immature, ineffective, irresponsible, weak, unreliable, and blaming. C reflects the degree of an individual’s perception of himself/herself as part of society. This has five subdimensions: C1, social acceptance versus social intolerance; C2, empathy versus social disinterest; C3, helpfulness versus unhelpfulness; C4, compassion versus revengefulness; and C5, purehearted principles versus self-advantage. High C corresponds to a tendency to be socially tolerant, helpful, and emphatic, whereas low C corresponds to a tendency to be socially intolerant, unhelpful, and vengeful. ST expresses the degree to which the self is viewed as an integral part of the universe and includes three subdimensions: ST1, self-forgetful versus self-conscious; ST2, transpersonal identification versus self-differentiation; and ST3, spiritual acceptance versus rational materialism (Cloninger et al., 1993; Cloninger, 1994).
Beck Depression Inventory The BDI is a 21-item self-report questionnaire that assesses the presence or the severity of depressive symptoms. Each item is scored from 0 to 3. Total BDI score is calculated by summing the scores of all 21 items. Validity and reliability of the Turkish version of the BDI were investigated by Hisli (1989).
patients with relapsing (relapsing remitting MS [RRMS]) and progressive forms (primary progressive MS [PPMS] and secondary progressive MS [SPMS]) of the disease using ANCOVA, with depression and age as covariates. Pearson’s correlation analyses were used to determine the correlation between the BDI scores and TCI scores, the duration of the disease, and EDSS scores. Partial correlation analysis was used to determine the relationship between the TCI scores, the duration of the disease, and EDSS to control for depression. All correlation analyses were performed for both MS patients and the control group. Statistical significance was set at a p-value of 0.05.
RESULTS The MS group consisted of 43 women and 31 men (aged 18Y57 years; mean [SD] age, 34.6 [9.2]), and the control group consisted of 43 women and 31 men (aged 18Y56 years; mean [SD] age, 35.1 [9]). Sixty-four patients had RRMS, five had PPMS, and five had SPMS. The median duration of the disease was 6.4 years (mean [SD], 8.6 [6.3]), and the mean [SD] EDSS score was 2.5 [1.8]. There were no significant differences in age, sex, or length of education between the groups (p = 0.87 for age, p = 0.56 for sex, and p = 0.48 for length of education). The mean BDI scores of the MS patients were significantly higher than those of the control group (p G 0.05). Demographic characteristics and BDI scores of the study population are shown in Table 1. Comparison of the main TCI dimension scores between the groups revealed significantly higher HA scores (p = 0.009) and lower SD scores (p = 0.01) in the MS patients than in the controls. Subdimension-level analysis revealed higher scores in HA4 (p G 0.001) and lower scores in SD2 and SD3 (p = 0.007 and p = 0.002, respectively) in the MS patients than in the controls. There were no significant differences in other higher dimensions between the MS patients and the control group. Regarding subdimension-level analysis, C3 scores were higher and C5 scores were lower in the MS patients than in the control group (p = 0.04 and p = 0.002, respectively). When depression was used as covariate, there was no longer a significant difference in HA and SD scores, but subdimension-level analysis still revealed higher scores in HA4 (p G 0.001) and C3 (p G 0.05) and lower scores in SD3 (p G 0.05) in the MS patients compared with the controls. Means and adjusted mean values of TCI scores and the comparisons of TCI scores between the MS patients and the control subjects are shown in Table 2. BDI scores of the MS patients were positively correlated with HA (r = 0.526, p G 0.001) and negatively correlated with NS (r = j0.241, p = 0.03), RD (r = j0.291, p = 0.01), SD (r = j0.526, p G 0.001), and C scores (r = j0.289, p = 0.01) in the MS patients. The BDI scores were positively correlated with HA (r = 0.468, p G 0.001) and ST scores (r = 0.230, p = 0.04) and negatively correlated with SD (r = j0.519, p G 0.001) and C scores (r = j0.269, p = 0.02) also in the control group. BDI scores were not correlated with the duration of the disease and EDSS scores. TABLE 1. Demographic Features and BDI Scores of the Groups
Data Analysis The questionnaires were coded using a standard key, and all data were analyzed using the Statistical Package for the Social Sciences for Windows version 15. Demographic variables were compared between the MS patients and the controls using Student’s t-test for continuous variables and the chi-square test for categorical variables. Because TCI scores were influenced by depression and the mean BDI scores of the MS patients were higher than those of the control group, adjusted mean values of TCI scores were calculated and TCI dimension scores were compared using analysis of covariance (ANCOVA), with depression as covariate. TCI dimension scores were also compared between the * 2014 Lippincott Williams & Wilkins
Personality in Multiple Sclerosis
Age Female/male Education duration, yrs Disease duration, yrs EDSS BDI score
MS Patients (n = 74)
Control Subjects (n = 74)
p*
34.6 (9.2) 43/31 11 8.6 (6.3) 2.5 (1.8) 12.2 (8.2)
35.1 (9) 43/31 11
0.87 0.56 0.48
8.7 (7.1)
0.006
Data written bold in the table is significant. *p-value; t-test for age and BDI, Mann-Whitney’s U test for education duration, chisquare test for sex; significant if less than 0.05.
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TABLE 2. Means and Adjusted Mean Values of TCI Scores of MS Patients and the Control Subjects
NS NS1 NS2 NS3 NS4 HA HA1 HA2 HA3 HA4 RD RD1 RD3 RD4 P SD SD1 SD2 SD3 SD4 SD5 C C1 C2 C3 C4 C5 ST ST1 ST2 ST3
MS Patients (n = 74)
Control Subjects (n = 74)
p
p*
16.5 (4.9) (16.5) 5.7 (2.2) (5.8) 3.8 (1.7) (3.7) 3.7 (1.8) (3.7) 3.2 (1.6) (3.2) 19.3 (6.1) (18.6) 5.9 (2.2) (5.7) 4.6 (1.4) (4.5) 3.6 (2.1) (3.4) 5 (2.2) (4.8) 14.5 (2.9) (14.6) 7.7 (1.6) (7.6) 4.4 (1.7) (4.5) 2.4 (1.2) (2.4) 5 (1.8) (4.9) 28.6 (6) (29.3) 4.9 (1.9) (5.1) 5.8 (1.4) (6) 2.9 (1.3) (3) 6.2 (2.4) (6.3) 8.5 (1.9) (8.7) 29.8 (5.3) (30.1) 5.8 (1.7) (6) 3.8 (1.4) (3.9) 5.3 (1.1) (5.4) 7.6 (2.4) (7.6) 7 (1.2) (7.1) 18.1 (5.3) (17.9) 5.3 (2.2) (5.1) 5.3 (2.1) (5.2) 7.5 (2.5) (7.5)
16.5 (4.8) (16.4) 5.4 (1.9) (5.2) 3.5 (1.8) (3.5) 4.3 (2.2) (4.4) 3.1 (1.7) (3.2) 16.6 (5.9) (17.3) 5.7 (2.1) (5.9) 4.2 (1.6) (4.3) 3.2 (2) (3.4) 3.3 (1.9) (3.5) 14.6 (3) (14.6) 7.4 (1.9) (7.5) 4.3 (1.5) (4.1) 2.8 (1.4) (2.8) 5.5 (1.7) (5.5) 30.9 (5.6) (30.2) 5.2 (2) (5) 6.5 (1.2) (6.3) 3.6 (1.1) (3.5) 6.5 (2.7) (6.4) 8.9 (1.5) (8.8) 30.6 (5.3) (30.3) 6 (1.5) (5.9) 4.3 (1.3) (4.3) 4.9 (1.3) (4.9) 7.7 (2.5) (7.6) 7.6 (1.3) (7.5) 18.6 (5.4) (18.7) 5.3 (2.6) (5.5) 4.9 (2.3) (4.9) 8.2 (2.4) (8.2)
0.9 0.39 0.35 0.08 0.73 0.009 0.57 0.12 0.29 G0.001 0.8 0.63 0.72 0.07 0.06 0.01 0.3 0.007 0.002 0.43 0.36 0.34 0.77 0.07 0.04 0.75 0.002 0.58 0.85 0.36 0.06
0.917 0.107 0.555 0.056 0.934 0.144 0.477 0.555 0.851 G0.001 0.957 0.792 0.160 0.063 0.05 0.286 0.826 0.102 0.022 0.763 0.811 0.855 0.726 0.110 0.017 0.949 0.052 0.419 0.408 0.384 0.08
Values are presented as mean (standard deviation) (adjusted mean). Data written bold in the table are significant. *p-value from ANCOVA.
The duration of the disease was positively correlated with HA (r = 0.254, p = 0.02) and negatively correlated with NS scores (r = j0.239, p = 0.04). After controlling for depression, the duration of the disease was still correlated positively with HA and negatively with NS scores. EDSS scores were negatively correlated with NS (r = j0.236, p = 0.04) and RD scores (r = j0.283, p = 0.01). After controlling for depression, EDSS scores were only negatively correlated with RD scores (r = j0.242, p = 0.03). When main TCI dimension scores were compared between the patients with relapsing (n = 64) and progressive forms (n = 10) of the disease, the only significant difference was between the RD scores of the two groups (p G 0.05). The patients with progressive forms of the disease had lower RD scores (12 [3.9]) than the patients with a relapsing form (14.9 [2.5]).
DISCUSSION In this study, we investigated the personality traits of MS patients and their relationship with clinical characteristics. The MS patients exhibited higher HA and lower SD scores than the healthy controls in terms of the main TCI dimensions. However, after controlling for 410
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depression, no significant difference remained between the MS patients and the control group. This finding is consistent with those from previous studies that reported higher HA and lower SD scores during depression (Celikel et al., 2009; Smith et al., 2005). We also found a highly significant positive correlation between BDI scores and HA scores and a negative correlation between BDI scores and SD scores in both MS patients and the control group. This again confirms the influence of depression on these dimensions. At subscale-level analyses, we determined higher HA4 and C3 scores and lower SD3 scores in the MS patients than in the control group after controlling for depression. This indicates that MS patients may have less energy, have a tendency to tiredness and be easily fatigued (HA4), like to cooperate with others, and like to work as part of a team rather than working alone (C3). It also suggests that they are passive in coping with problems and usually wait for others to solve them (SD3) (Cloninger et al., 1993). Ozura et al. (2010) also reported an avoidant style of coping with problems in MS patients, similar to our findings of passivity in coping with problems. Only two studies have used the TCI for the assessment of personality in MS patients (Christodoulou et al., 1999; Fazekas et al., 2013), and only one compared the patients with control subjects, reporting higher HA and lower RD and P in MS patients than in the controls (Christodoulou et al., 1999). However, they did not measure the depressive symptoms of the patients and did not consider the influence of depression on TCI scores. Depression is well known to be very common in MS patients, as in many chronic neurological or medical diseases, and may influence the individual scores of Cloninger’s dimensions (Celikel et al., 2009; Smith et al., 2005). We also determined higher depression scores in the MS patients than in the control group, consistent with the literature (Beiske et al., 2008; Chwastiak et al., 2002; Paparrigopoulos et al., 2010). Our results also corroborate the influence of depression on the TCI scores. Other studies that used different instruments for the assessment of personality most commonly reported increased neuroticism in MS patients (Gioia et al., 2009; Merkelbach et al., 2003; Penner et al., 2007). Neuroticism is known to be related to increased HA and decreased SD levels. Both neuroticism and higher HA and lower SD are known to be associated with depression (Celikel et al., 2009; De Fruyt et al., 2000; Jylha and Isometsa, 2006; Smith et al., 2005). We also determined higher HA and lower SD levels in the MS patients that disappeared after controlling for depression. The higher neuroticism levels in these previous studies may be associated with depression, in agreement with our results. It has previously been suggested that personality characteristics may influence the course of a chronic disease by affecting coping mechanisms or that the chronic disease itself may alter the personality in various ways. Although some personality traits are thought to remain stable over time, it is known that some environmental factors or medical diseases may influence them (Christodoulou et al., 1999; Johnson et al., 1996; Stathopoulou et al., 2010). Moreover, there is a known correlation between temperament dimensions and specific neurotransmitter system activities that can be influenced by the damage caused by MS (Bruce and Lynch, 2011; Christodoulou et al., 1999; Cloninger, 1987; Cloninger et al., 1993; Stathopoulou et al., 2010). We found that longer disease duration corresponds to higher HA and lower NS scores. Individuals with high HA are usually characterized as serenity seeking, passive, unassertive, patient, and introverted if they also have low NS (Cloninger, 1987). We also found that high EDSS corresponds to low RD scores, which are characterized as socially insensitive and tough minded (Cloninger, 1987). Possibly because of this correlation, we found lower RD scores in the patients with progressive forms of the disease than the relapsing form. High HA and low NS and RD scores have also been reported to be associated with low extraversion in a study that investigated the relationships between Cloninger’s model and the Five-Factor Model (De Fruyt et al., 2000). Gioia et al. (2009) reported a significant negative correlation between extraversion and EDSS in their cognitively preserved MS patients, in agreement with our results. * 2014 Lippincott Williams & Wilkins
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Personality in Multiple Sclerosis
Benedict et al. (2008) reported significant associations between low extraversion, openness and conscientiousness, and cortical atrophy. Both these studies and our study suggest that different personality features can be identified in the early or late stages of MS. This finding may also explain the different results of studies investigating personality characteristics in MS patients due to the different characteristics of the study populations involved. Personality traits have also been investigated in some other chronic neurological diseases, such as Parkinson’s disease, epilepsy, migraine, and tension-type headache (TTH) (Boz et al., 2004; Poletti and Bonuccelli, 2012; Yazici et al., 2013). Poletti and Bonuccelli (2012) reported low NS scores, probably due to low dopaminergic activity, and high HA scores, probably associated with comorbid affective disorders, in Parkinson’s disease. Yazici et al. (2013) reported higher HA and lower P, SD, and C in epileptic patients and emphasized the role of comorbid depression in lower SD scores. Boz et al. (2004) reported higher HA scores in patients with TTH but no distinctive personality features in patients with migraine, using depression scores as covariate. They also reported a significant effect of depression scores on HA, SD, and C. In addition to the different findings regarding personality traits for each disease in different studies, a noteworthy finding in the studies cited above was higher depression scores in all patient groups than in the controls, similar to our findings in MS patients. This finding emphasizes the importance of the evaluation of the comorbid affective disorders while assessing personality in patients with a chronic disease. To the best of our knowledge, this is the first study to investigate personality characteristics of MS patients with the TCI by comparing them with a control group and to compare their relationships with the clinical characteristics. However, there are some limitations to this study. One is the cross-sectional design, which makes it difficult to draw conclusions concerning the causal relationships between personality characteristics, depression, and physical impairment. Another is the hospital-based design of the study population, which limits the possibility of generalizing the findings to the entire population. Another limitation is the assessment of patients without using a structured psychiatric interview for comorbid psychiatric disorders.
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CONCLUSIONS
Ozura A, Erdberg P, Sega S (2010) Personality characteristics of multiple sclerosis patients: A Rorschach investigation. Clin Neurol Neurosurg. 112:629Y632.
In conclusion, our findings suggest a possible correlation between personality characteristics and the degree of damage caused by the disease in MS patients. Future research with different subgroups of study populations, more comprehensive personality, psychiatric and cognitive evaluations, and functional magnetic resonance imaging investigations using a longitudinal design may be useful in corroborating these findings. DISCLOSURE The authors declare no conflict of interest. REFERENCES Beiske AG, Svensson E, Sandanger I, Czujko B, Pedersen ED, Aarseth JH, Myhr KM (2008) Depression and anxiety amongst multiple sclerosis patients. Eur J Neurol. 15:239Y245. Benedict RH, Hussein S, Englert J, Dwyer MG, Abdelrahman N, Cox JL, Munschauer FE, Weinstock-Guttman B, Zivadinov R (2008) Cortical atrophy and personality in multiple sclerosis. Neuropsychology. 22:432Y441. Benedict RH, Priore RL, Miller C, Munschauer F, Jacobs L (2001) Personality disorder in multiple sclerosis correlates with cognitive impairment. J Neuropsychiatry Clin Neurosci. 13:70Y76. Boz C, Velioglu S, Ozmenoglu M, Sayar K, Alioglu Z, Yalman B, Topbas M (2004) Temperament and character profiles of patients with tension-type headache and migraine. Psychiatry Clin Neurosci. 58:536Y543. Bruce JM, Lynch SG (2011) Personality traits in multiple sclerosis: Association with mood and anxiety disorders. J Psychosom Res. 70:479Y485.
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Personality Traits of Patients With Multiple Sclerosis and Their Relationship With Clinical Characteristics Sibel Gazioglu, MD,* Vildan Altunayoglu Cakmak, MD,* Evrim Ozkorumak, MD,Þ Nuray Can Usta, MD,* Can Ates, MSc,þ and Cavit Boz, MD* Abstract: Few studies have investigated personality characteristics in people with multiple sclerosis (MS), and little is known about the relationship between personality and clinical characteristics in these patients. We aimed to investigate the personality traits of MS patients and their relationship with clinical characteristics. The study population consisted of 74 MS patients and age-matched, sex-matched, and education levelYmatched healthy controls. All participants were instructed to complete the self-administered 240-item Temperament and Character Inventory and the Beck Depression Inventory. The MS patients exhibited higher harm avoidance (HA) and lower self-directedness scores than the control group, although these differences disappeared after controlling for depression. Duration of the disease was positively correlated with HA and negatively correlated with novelty-seeking scores. Expanded Disability Status Scale scores were negatively correlated with reward dependence. Our results suggest a possible relationship between personality characteristics and the stage of the disease or the degree of damage in MS patients. Key Words: Multiple sclerosis, personality, temperament, character (J Nerv Ment Dis 2014;202: 408Y411)
M
ultiple sclerosis (MS) is a chronic demyelinating disease of the CNS that can lead to serious disability and impairs the quality of life. In addition to progressive neurological disability, neuropsychiatric symptoms and personality changes have also been reported in MS patients (Paparrigopoulos et al., 2010; Stathopoulou et al., 2010). Personality is a composite of individual behavioral, mental, and emotional response patterns. There are a number of models that assess personality traits and explain underlying biological interactions. Cloninger described a dimensional psychobiological model of personality that investigates seven personality traits referring to temperament and character. The Temperament and Character Inventory (TCI) was developed to assess the dimensions of personality. According to Cloninger’s model, dimensions of temperament consist of novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence (P), and dimensions of character consist of self-directedness (SD), cooperativeness (C), and self-transcendence (ST). Temperament dimensions constitute the heritable part of personality, with a genetic component ranging from 40% to 60%, and have been shown to be correlated with specific neurotransmitter system activities, such as dopamine, serotonin, and noradrenalin. Character dimensions are the external aspect of personality and are determined more environmentally, with a low genetic component ranging from 10% to 15% (Cloninger, 1987, 1994; Cloninger et al., 1993).
Departments of *Neurology, and †Psychiatry, Medical Faculty, Karadeniz Technical University, Trabzon, Turkey; and ‡Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey. Send reprint requests to Sibel Gazioglu, MD, Department of Neurology, Medical Faculty, Karadeniz Technical University, 61080 Trabzon, Turkey. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20205Y0408 DOI: 10.1097/NMD.0000000000000114
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Personality characteristics in MS patients have been evaluated using different instruments in previous studies (Benedict et al., 2001; Bruce and Lynch, 2011; Christodoulou et al., 1999; Fazekas et al., 2013; Gioia et al., 2009; Johnson et al., 1996; Merkelbach et al., 2003; Ozura et al., 2010; Penner et al., 2007; Ra¨tsep et al., 2000). Dimensional evaluation of personality using the TCI provides a systematic and comprehensive approach and has the advantage of evaluating personality profiles that do not always mean a personality disorder (Cloninger et al., 1993; Svrakic et al., 1993). The aims of this study were to determine the temperament and character profiles of MS patients and to investigate their relationship with clinical characteristics, such as disease duration and severity.
METHODS Subjects Seventy-four patients with definite MS according to the McDonald criteria were recruited from our MS outpatient clinic (Polman et al., 2005). Patients older than 18 years with at least primary school education and a diagnosis of MS for at least 1 year were included. Patients with mental and social retardation to understand the tests; with a diagnosis of a psychotic disorder that might interfere with clinical interview; with concurrent medical conditions such as cardiac, hepatic, renal, blood, or circulatory disorders; and with MS exacerbation or receiving corticosteroids within the preceding 3 months were excluded. Seventy-four age-matched, sex-matched, and education levelY matched control subjects were chosen at random from hospital staff, students at the medical school, and the general population by face-to-face interview. All participants underwent a detailed medical examination, including medical history, full neurological examinations, and a psychiatric interview. The duration of the disease according to the reported date of diagnosis and confirmed from the medical records and type of MS were recorded. The Kurtzke Expanded Disability Status Scale (EDSS) scale was used to measure disability (Kurtzke, 1983). All participants were instructed to complete the questionnaires, including the TCI and the Beck Depression Inventory (BDI), in a quiet room. The ethical committee approved the study, and informed consent was obtained from each subject.
Measures Temperament and Character Inventory Personality was assessed using a self-administered TCI questionnaire consisting of 240 true-false items. The TCI assesses four temperament (NS, HA, RD, and P) and three character (SD, C, and ST) dimensions of personality. The validity and reliability of the Turkish version of the TCI were reported in a recent study (Kose et al., 2004). NS reflects a heritable tendency toward behavioral activation for innovation, active avoidance of punishment or disappointment, and exaggeration in the approach to cues for potential rewards. NS includes four subdimensions: NS1, exploratory excitability versus stoic rigidity; NS2, impulsiveness versus reflection; NS3, extravagance versus reserve; and NS4, disorderliness versus regimentation. Low NS corresponds to being slow tempered, reflective, uninquiring, and tolerant of monotonous states. High NS corresponds to excitement and
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enthusiastic exploration of novel stimuli, while having the disadvantages of impulsivity, becoming bored quickly, and inattention to detail. HA reflects a heritable tendency toward behavioral inhibition to avoid nonrewarding or negative stimuli and punishment. HA consists of four subdimensions: HA1, anticipatory worry and pessimism versus uninhibited optimism; HA2, fear or uncertainty versus confidence; HA3, shyness with strangers versus gregariousness; and HA4, fatigability and asthenia versus vigor. High HA corresponds to shyness, fear of uncertainty, and easy fatigability that leads to social inhibition and anxiety. Low HA corresponds to being relaxed, energetic, courageous, and optimistic and has the disadvantages of excessive optimism and inappropriate responses even in serious danger. RD reflects a heritable tendency toward intense response to signals of social rewards and maintenance of behavior previously associated with rewards. RD includes three subdimensions: RD1, sentimentality versus insensitivity; RD3, attachment versus detachment; and RD4, dependence versus independence. High reward-dependent individuals are described as sentimental and socially sensitive, although excessive social attachment and dependence on the approval of others may influence their objectivity. Low reward-dependent individuals are described as tough minded, cool, socially insensitive, and independent. P reflects a heritable tendency toward maintenance of behavior as resistance to frustration. High P corresponds to perseverance, ambition, diligence, and perfectionism. In contrast, individuals with low P are described as inactive, indolent, and unstable. SD is the first dimension of character and the major determinant of the presence of personality disorder. SD reflects the ability to regulate and adapt behavior according to the situation to achieve individually chosen goals and values. SD has five subdimensions: SD1, responsibility versus blaming; SD2, purposefulness versus lack of goal or direction; SD3, resourcefulness versus inertia; SD4, self-acceptance versus self-striving; and SD5, congruent second nature versus incongruent habits. Individuals with high SD are described as mature, self-sufficient, and reliable with high respect and confidence. Individuals with low SD, on the other hand, are described as immature, ineffective, irresponsible, weak, unreliable, and blaming. C reflects the degree of an individual’s perception of himself/herself as part of society. This has five subdimensions: C1, social acceptance versus social intolerance; C2, empathy versus social disinterest; C3, helpfulness versus unhelpfulness; C4, compassion versus revengefulness; and C5, purehearted principles versus self-advantage. High C corresponds to a tendency to be socially tolerant, helpful, and emphatic, whereas low C corresponds to a tendency to be socially intolerant, unhelpful, and vengeful. ST expresses the degree to which the self is viewed as an integral part of the universe and includes three subdimensions: ST1, self-forgetful versus self-conscious; ST2, transpersonal identification versus self-differentiation; and ST3, spiritual acceptance versus rational materialism (Cloninger et al., 1993; Cloninger, 1994).
Beck Depression Inventory The BDI is a 21-item self-report questionnaire that assesses the presence or the severity of depressive symptoms. Each item is scored from 0 to 3. Total BDI score is calculated by summing the scores of all 21 items. Validity and reliability of the Turkish version of the BDI were investigated by Hisli (1989).
patients with relapsing (relapsing remitting MS [RRMS]) and progressive forms (primary progressive MS [PPMS] and secondary progressive MS [SPMS]) of the disease using ANCOVA, with depression and age as covariates. Pearson’s correlation analyses were used to determine the correlation between the BDI scores and TCI scores, the duration of the disease, and EDSS scores. Partial correlation analysis was used to determine the relationship between the TCI scores, the duration of the disease, and EDSS to control for depression. All correlation analyses were performed for both MS patients and the control group. Statistical significance was set at a p-value of 0.05.
RESULTS The MS group consisted of 43 women and 31 men (aged 18Y57 years; mean [SD] age, 34.6 [9.2]), and the control group consisted of 43 women and 31 men (aged 18Y56 years; mean [SD] age, 35.1 [9]). Sixty-four patients had RRMS, five had PPMS, and five had SPMS. The median duration of the disease was 6.4 years (mean [SD], 8.6 [6.3]), and the mean [SD] EDSS score was 2.5 [1.8]. There were no significant differences in age, sex, or length of education between the groups (p = 0.87 for age, p = 0.56 for sex, and p = 0.48 for length of education). The mean BDI scores of the MS patients were significantly higher than those of the control group (p G 0.05). Demographic characteristics and BDI scores of the study population are shown in Table 1. Comparison of the main TCI dimension scores between the groups revealed significantly higher HA scores (p = 0.009) and lower SD scores (p = 0.01) in the MS patients than in the controls. Subdimension-level analysis revealed higher scores in HA4 (p G 0.001) and lower scores in SD2 and SD3 (p = 0.007 and p = 0.002, respectively) in the MS patients than in the controls. There were no significant differences in other higher dimensions between the MS patients and the control group. Regarding subdimension-level analysis, C3 scores were higher and C5 scores were lower in the MS patients than in the control group (p = 0.04 and p = 0.002, respectively). When depression was used as covariate, there was no longer a significant difference in HA and SD scores, but subdimension-level analysis still revealed higher scores in HA4 (p G 0.001) and C3 (p G 0.05) and lower scores in SD3 (p G 0.05) in the MS patients compared with the controls. Means and adjusted mean values of TCI scores and the comparisons of TCI scores between the MS patients and the control subjects are shown in Table 2. BDI scores of the MS patients were positively correlated with HA (r = 0.526, p G 0.001) and negatively correlated with NS (r = j0.241, p = 0.03), RD (r = j0.291, p = 0.01), SD (r = j0.526, p G 0.001), and C scores (r = j0.289, p = 0.01) in the MS patients. The BDI scores were positively correlated with HA (r = 0.468, p G 0.001) and ST scores (r = 0.230, p = 0.04) and negatively correlated with SD (r = j0.519, p G 0.001) and C scores (r = j0.269, p = 0.02) also in the control group. BDI scores were not correlated with the duration of the disease and EDSS scores. TABLE 1. Demographic Features and BDI Scores of the Groups
Data Analysis The questionnaires were coded using a standard key, and all data were analyzed using the Statistical Package for the Social Sciences for Windows version 15. Demographic variables were compared between the MS patients and the controls using Student’s t-test for continuous variables and the chi-square test for categorical variables. Because TCI scores were influenced by depression and the mean BDI scores of the MS patients were higher than those of the control group, adjusted mean values of TCI scores were calculated and TCI dimension scores were compared using analysis of covariance (ANCOVA), with depression as covariate. TCI dimension scores were also compared between the * 2014 Lippincott Williams & Wilkins
Personality in Multiple Sclerosis
Age Female/male Education duration, yrs Disease duration, yrs EDSS BDI score
MS Patients (n = 74)
Control Subjects (n = 74)
p*
34.6 (9.2) 43/31 11 8.6 (6.3) 2.5 (1.8) 12.2 (8.2)
35.1 (9) 43/31 11
0.87 0.56 0.48
8.7 (7.1)
0.006
Data written bold in the table is significant. *p-value; t-test for age and BDI, Mann-Whitney’s U test for education duration, chisquare test for sex; significant if less than 0.05.
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TABLE 2. Means and Adjusted Mean Values of TCI Scores of MS Patients and the Control Subjects
NS NS1 NS2 NS3 NS4 HA HA1 HA2 HA3 HA4 RD RD1 RD3 RD4 P SD SD1 SD2 SD3 SD4 SD5 C C1 C2 C3 C4 C5 ST ST1 ST2 ST3
MS Patients (n = 74)
Control Subjects (n = 74)
p
p*
16.5 (4.9) (16.5) 5.7 (2.2) (5.8) 3.8 (1.7) (3.7) 3.7 (1.8) (3.7) 3.2 (1.6) (3.2) 19.3 (6.1) (18.6) 5.9 (2.2) (5.7) 4.6 (1.4) (4.5) 3.6 (2.1) (3.4) 5 (2.2) (4.8) 14.5 (2.9) (14.6) 7.7 (1.6) (7.6) 4.4 (1.7) (4.5) 2.4 (1.2) (2.4) 5 (1.8) (4.9) 28.6 (6) (29.3) 4.9 (1.9) (5.1) 5.8 (1.4) (6) 2.9 (1.3) (3) 6.2 (2.4) (6.3) 8.5 (1.9) (8.7) 29.8 (5.3) (30.1) 5.8 (1.7) (6) 3.8 (1.4) (3.9) 5.3 (1.1) (5.4) 7.6 (2.4) (7.6) 7 (1.2) (7.1) 18.1 (5.3) (17.9) 5.3 (2.2) (5.1) 5.3 (2.1) (5.2) 7.5 (2.5) (7.5)
16.5 (4.8) (16.4) 5.4 (1.9) (5.2) 3.5 (1.8) (3.5) 4.3 (2.2) (4.4) 3.1 (1.7) (3.2) 16.6 (5.9) (17.3) 5.7 (2.1) (5.9) 4.2 (1.6) (4.3) 3.2 (2) (3.4) 3.3 (1.9) (3.5) 14.6 (3) (14.6) 7.4 (1.9) (7.5) 4.3 (1.5) (4.1) 2.8 (1.4) (2.8) 5.5 (1.7) (5.5) 30.9 (5.6) (30.2) 5.2 (2) (5) 6.5 (1.2) (6.3) 3.6 (1.1) (3.5) 6.5 (2.7) (6.4) 8.9 (1.5) (8.8) 30.6 (5.3) (30.3) 6 (1.5) (5.9) 4.3 (1.3) (4.3) 4.9 (1.3) (4.9) 7.7 (2.5) (7.6) 7.6 (1.3) (7.5) 18.6 (5.4) (18.7) 5.3 (2.6) (5.5) 4.9 (2.3) (4.9) 8.2 (2.4) (8.2)
0.9 0.39 0.35 0.08 0.73 0.009 0.57 0.12 0.29 G0.001 0.8 0.63 0.72 0.07 0.06 0.01 0.3 0.007 0.002 0.43 0.36 0.34 0.77 0.07 0.04 0.75 0.002 0.58 0.85 0.36 0.06
0.917 0.107 0.555 0.056 0.934 0.144 0.477 0.555 0.851 G0.001 0.957 0.792 0.160 0.063 0.05 0.286 0.826 0.102 0.022 0.763 0.811 0.855 0.726 0.110 0.017 0.949 0.052 0.419 0.408 0.384 0.08
Values are presented as mean (standard deviation) (adjusted mean). Data written bold in the table are significant. *p-value from ANCOVA.
The duration of the disease was positively correlated with HA (r = 0.254, p = 0.02) and negatively correlated with NS scores (r = j0.239, p = 0.04). After controlling for depression, the duration of the disease was still correlated positively with HA and negatively with NS scores. EDSS scores were negatively correlated with NS (r = j0.236, p = 0.04) and RD scores (r = j0.283, p = 0.01). After controlling for depression, EDSS scores were only negatively correlated with RD scores (r = j0.242, p = 0.03). When main TCI dimension scores were compared between the patients with relapsing (n = 64) and progressive forms (n = 10) of the disease, the only significant difference was between the RD scores of the two groups (p G 0.05). The patients with progressive forms of the disease had lower RD scores (12 [3.9]) than the patients with a relapsing form (14.9 [2.5]).
DISCUSSION In this study, we investigated the personality traits of MS patients and their relationship with clinical characteristics. The MS patients exhibited higher HA and lower SD scores than the healthy controls in terms of the main TCI dimensions. However, after controlling for 410
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depression, no significant difference remained between the MS patients and the control group. This finding is consistent with those from previous studies that reported higher HA and lower SD scores during depression (Celikel et al., 2009; Smith et al., 2005). We also found a highly significant positive correlation between BDI scores and HA scores and a negative correlation between BDI scores and SD scores in both MS patients and the control group. This again confirms the influence of depression on these dimensions. At subscale-level analyses, we determined higher HA4 and C3 scores and lower SD3 scores in the MS patients than in the control group after controlling for depression. This indicates that MS patients may have less energy, have a tendency to tiredness and be easily fatigued (HA4), like to cooperate with others, and like to work as part of a team rather than working alone (C3). It also suggests that they are passive in coping with problems and usually wait for others to solve them (SD3) (Cloninger et al., 1993). Ozura et al. (2010) also reported an avoidant style of coping with problems in MS patients, similar to our findings of passivity in coping with problems. Only two studies have used the TCI for the assessment of personality in MS patients (Christodoulou et al., 1999; Fazekas et al., 2013), and only one compared the patients with control subjects, reporting higher HA and lower RD and P in MS patients than in the controls (Christodoulou et al., 1999). However, they did not measure the depressive symptoms of the patients and did not consider the influence of depression on TCI scores. Depression is well known to be very common in MS patients, as in many chronic neurological or medical diseases, and may influence the individual scores of Cloninger’s dimensions (Celikel et al., 2009; Smith et al., 2005). We also determined higher depression scores in the MS patients than in the control group, consistent with the literature (Beiske et al., 2008; Chwastiak et al., 2002; Paparrigopoulos et al., 2010). Our results also corroborate the influence of depression on the TCI scores. Other studies that used different instruments for the assessment of personality most commonly reported increased neuroticism in MS patients (Gioia et al., 2009; Merkelbach et al., 2003; Penner et al., 2007). Neuroticism is known to be related to increased HA and decreased SD levels. Both neuroticism and higher HA and lower SD are known to be associated with depression (Celikel et al., 2009; De Fruyt et al., 2000; Jylha and Isometsa, 2006; Smith et al., 2005). We also determined higher HA and lower SD levels in the MS patients that disappeared after controlling for depression. The higher neuroticism levels in these previous studies may be associated with depression, in agreement with our results. It has previously been suggested that personality characteristics may influence the course of a chronic disease by affecting coping mechanisms or that the chronic disease itself may alter the personality in various ways. Although some personality traits are thought to remain stable over time, it is known that some environmental factors or medical diseases may influence them (Christodoulou et al., 1999; Johnson et al., 1996; Stathopoulou et al., 2010). Moreover, there is a known correlation between temperament dimensions and specific neurotransmitter system activities that can be influenced by the damage caused by MS (Bruce and Lynch, 2011; Christodoulou et al., 1999; Cloninger, 1987; Cloninger et al., 1993; Stathopoulou et al., 2010). We found that longer disease duration corresponds to higher HA and lower NS scores. Individuals with high HA are usually characterized as serenity seeking, passive, unassertive, patient, and introverted if they also have low NS (Cloninger, 1987). We also found that high EDSS corresponds to low RD scores, which are characterized as socially insensitive and tough minded (Cloninger, 1987). Possibly because of this correlation, we found lower RD scores in the patients with progressive forms of the disease than the relapsing form. High HA and low NS and RD scores have also been reported to be associated with low extraversion in a study that investigated the relationships between Cloninger’s model and the Five-Factor Model (De Fruyt et al., 2000). Gioia et al. (2009) reported a significant negative correlation between extraversion and EDSS in their cognitively preserved MS patients, in agreement with our results. * 2014 Lippincott Williams & Wilkins
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Personality in Multiple Sclerosis
Benedict et al. (2008) reported significant associations between low extraversion, openness and conscientiousness, and cortical atrophy. Both these studies and our study suggest that different personality features can be identified in the early or late stages of MS. This finding may also explain the different results of studies investigating personality characteristics in MS patients due to the different characteristics of the study populations involved. Personality traits have also been investigated in some other chronic neurological diseases, such as Parkinson’s disease, epilepsy, migraine, and tension-type headache (TTH) (Boz et al., 2004; Poletti and Bonuccelli, 2012; Yazici et al., 2013). Poletti and Bonuccelli (2012) reported low NS scores, probably due to low dopaminergic activity, and high HA scores, probably associated with comorbid affective disorders, in Parkinson’s disease. Yazici et al. (2013) reported higher HA and lower P, SD, and C in epileptic patients and emphasized the role of comorbid depression in lower SD scores. Boz et al. (2004) reported higher HA scores in patients with TTH but no distinctive personality features in patients with migraine, using depression scores as covariate. They also reported a significant effect of depression scores on HA, SD, and C. In addition to the different findings regarding personality traits for each disease in different studies, a noteworthy finding in the studies cited above was higher depression scores in all patient groups than in the controls, similar to our findings in MS patients. This finding emphasizes the importance of the evaluation of the comorbid affective disorders while assessing personality in patients with a chronic disease. To the best of our knowledge, this is the first study to investigate personality characteristics of MS patients with the TCI by comparing them with a control group and to compare their relationships with the clinical characteristics. However, there are some limitations to this study. One is the cross-sectional design, which makes it difficult to draw conclusions concerning the causal relationships between personality characteristics, depression, and physical impairment. Another is the hospital-based design of the study population, which limits the possibility of generalizing the findings to the entire population. Another limitation is the assessment of patients without using a structured psychiatric interview for comorbid psychiatric disorders.
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CONCLUSIONS
Ozura A, Erdberg P, Sega S (2010) Personality characteristics of multiple sclerosis patients: A Rorschach investigation. Clin Neurol Neurosurg. 112:629Y632.
In conclusion, our findings suggest a possible correlation between personality characteristics and the degree of damage caused by the disease in MS patients. Future research with different subgroups of study populations, more comprehensive personality, psychiatric and cognitive evaluations, and functional magnetic resonance imaging investigations using a longitudinal design may be useful in corroborating these findings. DISCLOSURE The authors declare no conflict of interest. REFERENCES Beiske AG, Svensson E, Sandanger I, Czujko B, Pedersen ED, Aarseth JH, Myhr KM (2008) Depression and anxiety amongst multiple sclerosis patients. Eur J Neurol. 15:239Y245. Benedict RH, Hussein S, Englert J, Dwyer MG, Abdelrahman N, Cox JL, Munschauer FE, Weinstock-Guttman B, Zivadinov R (2008) Cortical atrophy and personality in multiple sclerosis. Neuropsychology. 22:432Y441. Benedict RH, Priore RL, Miller C, Munschauer F, Jacobs L (2001) Personality disorder in multiple sclerosis correlates with cognitive impairment. J Neuropsychiatry Clin Neurosci. 13:70Y76. Boz C, Velioglu S, Ozmenoglu M, Sayar K, Alioglu Z, Yalman B, Topbas M (2004) Temperament and character profiles of patients with tension-type headache and migraine. Psychiatry Clin Neurosci. 58:536Y543. Bruce JM, Lynch SG (2011) Personality traits in multiple sclerosis: Association with mood and anxiety disorders. J Psychosom Res. 70:479Y485.
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