Journal of Affective Disorders 174 (2015) 13–18
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Research report
Relationship between affective temperaments and aggression in euthymic patients with bipolar mood disorder and major depressive disorder B. Dolenc a,n, M.Z. Dernovšek b, L. Sprah a, R. Tavcar b, G. Perugi c, H.S. Akiskal d a
Sociomedical Institute, Research Centre of the Slovenian Academy of Sciences and Arts, Ljubljana, Slovenia University Psychiatric Clinic, Ljubljana, Slovenia c Institute of Behavioural Sciences, “G. De Lisio”, Department of Psychiatry, University of Pisa, Pisa, Italy d International Mood Disorder Centre, Department of Psychiatry at the University of California, San Diego, La Jolla, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 30 June 2014 Received in revised form 9 October 2014 Accepted 8 November 2014 Available online 20 November 2014
Background: So far there is a scarce of studies dealing with the relationship between different aspects of aggressive behaviour and affective temperaments among various mood disorders. The aim of the present study was to explore in a group of patients with affective mood disorders the relationship between affective temperaments and aggression. Methods: 100 consecutive outpatients in euthymic phase of mood disorders (46 with bipolar disorder— type I, 18 with bipolar disorder—type II and 36 with major depressive disorder) were self-assessed with the Aggression Questionnaire and the short version of Slovenian Temperament Evaluation of Memphis, Pisa, Paris and San Diego – Autoquestionnaire (TEMPS-A). Results: The factorial analysis of the TEMPS-A subscales revealed 2 main factors: Factor 1 (prominent cyclothymic profile) consisted of cyclothymic, depressive, irritable, and anxious temperaments and Factor 2 (prominent hyperthymic profile) which was represented by the hyperthymic temperament, and by depressive and anxious temperaments as negative components. Patients with prominent cyclothymic profile got their diagnosis later in their life and had significantly higher mean scores on anger and hostility (non-motor aggressive behaviour) compared with patients with prominent hyperthymic profile. Limitations: We included patients with different mood disorders, therefore the sample selection may influence temperamental and aggression profiles. We used self-report questionnaires which can elicit sociable desirable answers. Conclusion: Anger and hostility could represent stable personality characteristics of prominent cyclothymic profile that endure even in remission. It seems that distinct temperamental profile could serve as a good diagnostic and prognostic value for non-motor aspects of aggressive behaviour. & 2014 Elsevier B.V. All rights reserved.
Keywords: Affective temperament Aggression Bipolar disorder Major depressive disorder
1. Introduction Several psychiatric disorders, including mood disorders, have been associated with increased rates of aggression and violent behaviour (Ballester et al., 2012; Brennan et al., 2000; Corrigan and Watson, 2005; Faedda et al., 2014; Feldmann, 2001; Harford et al., 2013; Oquendo et al., 2000), which could also carry diagnostic, prognostic, and therapeutic implications. However, the evidence for interpersonal violence and violent crime in patients with bipolar disorder is less clear (Fazel et al., 2010). Perroud et al. (2011) report that patients with bipolar and major depressive disorders display more frequent and severe lifetime
n
Corresponding author. Tel.: þ 386 41 374 078. E-mail address: [email protected] (B. Dolenc).
http://dx.doi.org/10.1016/j.jad.2014.11.007 0165-0327/& 2014 Elsevier B.V. All rights reserved.
aggressive behaviours than healthy persons. Some data also indicate a higher criminality rate in bipolar patients in comparison with patients with unipolar major depression (Cassidy et al., 2002; Corrigan and Watson, 2005; Graz et al., 2009; Sato et al., 2003). A significant association was reported between criminal behaviours and sub-threshold and syndromal bipolar disorder (Zimmermann et al., 2009). Barlow et al. (2000) report that patients with bipolar disorder express more aggressive behaviour in comparison with patients with other Axis-I disorders. Retrospectively assessed violent behaviour before and after the age of 15 is also reported to be associated with bipolar disorder (Pulay et al., 2008). Some studies also revealed that the diagnosis of bipolar disorder significantly increased the likelihood of being incarcerated (Stoddard Dare et al., 2011). In the case of bipolar disorder, the National Comorbidity Survey showed that the 12-month adult population prevalence of violent behaviours was 2%, whereas it was 16% for adults with bipolar disorder (Corrigan and
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B. Dolenc et al. / Journal of Affective Disorders 174 (2015) 13–18
Watson, 2005). Corrigan and Watson (2005) report that for patients with bipolar disorder the odds ratio for violence is 9.5 higher in comparison with healthy controls, meaning that people with bipolar disorder will have a 9.5 times greater likelihood of reporting violent behaviours than those with no mental disorder. However, some authors report that self-directed violence is more strongly associated with mood disorder compared with other-directed violence (Harford et al., 2013). In a longitudinal study of individuals with bipolar disorder, Fazel et al. (2010) reported that there was an increased risk for violent crime among individuals with bipolar disorder, but most of the excess violent crime was associated with substance abuse comorbidity, whereas the risk associated with a bipolar disorder per se appeared low. Authors concluded that the association between bipolar disorder and violent crime seems to be largely mediated by substance abuse comorbidity. Some studies also revealed, that violent behaviour is associated particularly during mania, mixed episodes, or psychotic states (Latalova, 2009), whereas hostility and aggression have been assumed of particular importance as core features of manic and mixed states (Cassidy et al., 2002; Maj et al., 2003; Swann et al., 1994). Some authors report that the general rate of total offence is higher in the manic phase of bipolar disorder in comparison with the depressive phase, whereas the rate of homicide is higher in the depressive phase of bipolar disorder (Yoon et al., 2012). Corrigan and Watson (2005) also pointed out that when adjusting violence rates by population base rates, demographics including ethnicity and gender revealed to be a better predictor of violent behaviour than psychiatric diagnosis, leading to a conclusion that mental illness is only a weak predictor of violent behaviour. Kesic and Thomas (2014) also reported that having a history of prior mental disorder diagnoses is not associated with violence which again challenges the traditional stereotyped view about the violence risk posed by people with prior contact with mental health services. Different conclusions made by previous studies show that more research needs to be done on explaining the relationship between mental illness and violent behaviour. It could be that research summaries that stress the connection of violence and psychiatric disorder may be exacerbating the stigma of mental illness (Corrigan and Watson, 2005). Besides aggressive traits, affective temperament supposed to have an impact on the clinical manifestation of mood disorders and on their course as well (Akiskal and Akiskal, 2005; Akiskal et al., 1977, Hantouche et al., 1998). Akiskal et al. (1977) postulated that temperament could represent the earliest subclinical phenotype of mood disorders and could be a potential contributor to the bipolar spectrum (Akiskal and Pinto, 1999). Numerous studies reported of specific temperament profile in patients with bipolar disorder (Hantouche et al., 1998; Matsumoto et al., 2005; Mazzarini et al., 2009; Mendlowicz et al., 2005) and major depression (Matsumoto et al., 2005; Mazzarini et al., 2009). However the predictive value of affective temperaments on the outcome of the bipolar disorder still requires further research (Perugi et al., 2012). The intertwinement between temperament and aggressive behaviour has been known for several years (e.g. Buss and Perry, 1992). However, so far there is a scarce of studies dealing with different aspects of aggressive behaviour among various affective disorders (Brennan et al., 2000; Graz et al., 2009). Some studies show that there is an increased risk for violent crime among the unaffected siblings of individuals with bipolar disorder, which further weakens the relationship between bipolar disorder per se and violent crime and highlights the contribution of genetic or early environmental factors in families with bipolar disorder (Fazel et al., 2010). From this standpoint, the role of affective temperaments in violent behaviour in mood disorders comes even more to the front.
It is crucial to understand the relationship between affective mood disorders and aggressive behaviour together with temperamental traits as these violent behaviours are associated with an increased risk for individual and familial suffering, socioeconomic and legal problems (Ballester et al., 2012) and also with the suicidal risk (Oquendo et al., 2004). Specifically, it has been recognized that behavioural dysregulation characterizes suicidal behaviour with aggression being particularly salient (Oquendo et al., 2004; Perroud et al., 2011). Unresolved questions also persist about the state- versus trait- dependent nature of aggression and factors that mediate its expression in bipolar disorder and depression (Garno et al., 2008). The aim of the present study was to explore in a group of patients with mood disorders (bipolar disorder—type I, bipolar disorder—type II and Major Depressive Disorder), evaluated in euthymic phase of illness, the relationship between affective temperaments and aggression. We focused on the influence of affective temperament as a relatively stable trait (Gandotra and Paul, 2004) on different disease-related variables and different aspects of aggressive behaviour.
2. Methods 2.1. Subjects 100 consecutive outpatients with mood disorders were included in our study. The sample comprised of 64 (64%) patients with bipolar disorder (of that 46 with bipolar disorder—type I [BD I] and 18 patients with bipolar disorder—type II [BD II]) and 36 (36%) patients with major depressive disorder (MDD). 30 (30%) patients were males and 70 (70%) females. All patients were in euthymic phase of illness, according to ICD-10 diagnostic criteria. All patients were treated as outpatients in University Psychiatric Clinic Ljubljana in the year 2012. All patients were treated in full accordance with the routine clinical practice. The efficacy and the effectiveness of the treatments were not among the aims of the investigation. All subjects who were not in a stable mental or physical condition due to any cause, subjects who were not for 6 months in stable remission according to the case records, subjects with other psychiatric diagnoses, pregnant women, subjects already enrolled in other studies and subjects who were unable to give an informed consent were excluded from the study. All subjects included in our study gave written informed consent and had the chance to give up the study at any time.
2.2. Measures Two self-assessment questionnaires were used in our study. The Aggression Questionnaire (Buss and Perry, 1992) is constructed of four aggression subscales: physical aggression (hurting or harming others —instrumental or motor component of behaviour), verbal aggression (hurting or harming others—instrumental or motor component of behaviour), anger (physiological arousal and preparation for aggression—emotional or affective component of behaviour), and hostility (feelings of ill will and injustice—cognitive component of behaviour). The short version of Slovenian TEMPS-A Scale (Temperament Evaluation of Memphis, Pisa, Paris and San Diego – Autoquestionnaire, Akiskal et al., 2005) was used to measure five affective temperaments, namely depressive (increased sensitivity to life's sorrows and disappointments), cyclothymic (labile mood swings), hyperthymic (enterprising, ambitious and driven), irritable (angry and dissatisfied) and anxious (prone to worrying and anxiety).
B. Dolenc et al. / Journal of Affective Disorders 174 (2015) 13–18
2.3. Procedure The study was cross sectional. First, the state affectivity and all comorbid disorders in subjects with the history of mood disorder was clinically stated and confirmed by studying the case file by an experienced clinician. All patients who were not in euthymic phase of illness for at least 6 months, subjects with other psychiatric diagnoses (comorbid disorders), pregnant women and subject, who were already enrolled in other research projects, were excluded from our study. Subjects, who were in a stable remission phase and who had only diagnosis of affective mood disorders were further invited to participate in our research as studies show that self-reports of violent behaviour are much more frequent in people with more than one co-occurring disorder (Corrigan and Watson, 2005; Fazel et al., 2010). After explaining the patients the aim of the study, subjects gave informed consent. During the clinical interview information on demographic data, diagnostic and clinical features (comorbidity), as well as data on disease course and family history were collected. Lastly, the selfevaluations of temperamental and aggressive behaviour were conducted. The interview and filling out the questionnaires demanded about 1.5 h per subject. The study was approved by the National medical ethics committee. 2.4. Statistical analyses For all subjects, means of item sums for affective temperament subscales measured by TEMPS-A and Aggression Questionnaire subscales were calculated. We calculated differences in those scores between both groups of patients with t-test for independent samples. Next, the relationship between different affective temperaments and four types of aggressive behaviour has been examined and tested with Pearson's correlation coefficients. In Table 1 Means and standard deviations (in parenthesis) of the five subscales' sums from TEMPS-A (depressive, hyperthymic, cyclothymic, irritable and anxious subscale) and four subscales from Aggression Questionnaire (physical aggression, verbal aggression, anger and hostility subscale) for patients with MDD and BD I and II in remission. N¼ 100.
Depressive Cyclothymic Hyperthymic Irritable Anxious Physical aggression Verbal aggression Anger Hostility
MDD
BD I and II
t
p
2.9 3.8 4.4 2.5 3.9 14.8 13.4 17.2 19.9
3.6 4.3 4.5 2.7 4.7 15.8 13.2 19.8 19.6
1.07 .89 .09 .61 1.68 .78 .27 2.20 .216
ns ns ns ns ns ns ns .030 ns
(2.9) (2.8) (2.6) (2.4) (2.6) (5.8) (4.3) (5.9) (6.7)
(2.9) (2.2) (2.6) (2.1) (2.3) (6.2) (3.1) (4.6) (6.3)
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order to detect possible composite dimensions of different affective temperaments, a factorial analysis was performed on the TEMPS-A subscales. The initial factors were extracted by means of principal component analysis and then rotated according to Oblimin oblique rotation. Subjects' scores were then grouped into two dominant temperaments (according to factor analysis). To evaluate the differences in two dominant factors, the t-test and Chi-square test were used for the analyses of differences in several demographic and disease related variables between both groups of dominant temperament, respectively. P values lower than.05 were considered statistically significant. All statistical analyses were done with SPSS 20.0.
3. Results First, we calculated the differences between both groups of patients between affective temperaments and aggressive behaviour (Table 1). The mean scores of affective temperaments subscales' sums in TEMPS-A were the highest for hyperthymic, cyclothymic and anxious temperaments in both groups of patients, and the lowest for depressive and irritable temperaments. There were no statistically significant differences between both groups of patients. The mean scores of subscales' sums in Aggression Questionnaire were the highest for anger and hostility and the lowest for verbal aggression in both groups of patients. With the exception of the difference in mean scores of sums in anger no other statistically significant differences between MDD and BP I and II patients were found. Therefore we present the results for both groups together. Significant relationship between different affective temperaments exists (see Table 2). The score of depressive temperament was positively correlated with the scores of cyclothymic, irritable and anxious temperament and negatively with hyperthymic temperament. The score of cyclothymic temperament was positively correlated with the scores of depressive, irritable and anxious temperaments and negatively with hyperthymic temperament. The score of hyperthymic temperament was negatively correlated with all four temperaments, with the exception of the irritable temperament, where the correlation was not statistically significant. The score of irritable temperament was positively correlated with the scores of depressive, cyclothymic and anxious temperament. The score of anxious temperament was positively correlated with the scores of depressive, cyclothymic and irritable temperaments and negatively correlated with the score of hyperthymic temperament. There are many statistically significant correlations between scores on TEMPS-A subscales and scores on subscales of Aggression Questionnaire as well. The scores of cyclothymic and irritable temperament were positively correlated with all four scores of
Table 2 Pearson's correlation coefficients among affective temperament as measured by TEMPS-A (depressive, hyperthymic, cyclothymic, irritable and anxious subscale) and four subscales from Aggression Questionnaire (physical aggression, verbal aggression, anger and hostility subscale) for patients with mood disorder in remission. N ¼ 100.
Cyclothymic Hyperthymic Irritable Anxious Physical aggression Verbal aggression Anger Hostility n
po .05. p o.01.
nn
Depressive
Cyclothymic
Hyperthymic
Irritable
Anxious
Physical aggression
Verbal aggression
Anger
.70nn .43nn .49nn .52nn .10 .05 .32nn .51nn
– .24n .59nn .57nn .23n .27n .52nn .60nn
– .01 .32nn .16 .25n .02 .28nn
– .33nn .63nn .54nn .59nn .49nn
– .10 .09 .43nn .54nn
– .49nn .55nn .31nn
– .59nn .50nn
– .51nn
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Aggression Questionnaire. Depressive and anxious temperaments were positively correlated only with anger and hostility. Hyperthymic temperament was positively correlated with scores of verbal aggression and negatively correlated with the scores of hostility. Next, we conducted factor analysis to determine possible composite dimensions of affective temperaments (see Tables 3 and 4). Because of the high correlations between all the affective temperaments (see Table 2), we conducted a factor analysis with Oblimin oblique rotation. The factorial analysis of the mean scores of sums of the TEMPSA subscales showed 2 main factors in patients with mood disorders. Both factors explained 76% of the total variance. The first factor (55.39% of the variance) consisted of cyclothymic, depressive, irritable, and anxious temperament. The second factor (20.74% of variance) was represented by the hyperthymic temperament as the only positive component, and by depressive and anxious temperaments as negative components. We named these two factors according to the concept of mood reactivity, sensitivity and intensity as prominent cyclothymic and prominent hyperthymic, respectively. Factor 1 represents temperaments with prominent mood reactivity and sensitivity (prominent cyclothymic profile) and Factor 2 represents prominent mood intensity (prominent hyperthymic profile).
4. Discussion The aim of the present study was to explore in a group of patients with mood disorders (bipolar disorder—type I, bipolar Table 3 Factorial analysis (PCA extraction, Oblimin rotation) of TEMPS-A depressive, hyperthymic, cyclothymic, irritable and anxious subscale scores in patients with mood disorder in remission. Factor 1—prominent cyclothymic profile Depressive .82 Cyclothymic .89 Hyperthymic .24 Irritable .80 Anxious .69 Eigenvalue 2.77 % of variance 55.39
Factor 2—prominent hyperthymic profile .47 .23 .93 .19 .47 1.04 20.74
disorder—type II and Major Depressive Disorder) the relationship between affective temperaments and different aspects of aggressive behaviour. Temperament represents a relatively stable trait (Gandotra and Paul, 2004), therefore we focused on its influence on aggression and different variables related to mood disorders. First, we analysed the differences in affective temperaments and aggressive behaviour between patients with bipolar disorder and patients with major depressive disorder. Both groups of patients differed only in anger, whereas all the other differences were not significant. Previous studies report higher aggressive behaviour and criminality rate especially in the manic episode of bipolar disorder (Cassidy et al., 2002; Maj et al., 2003; Swann et al., 1994), whereas some authors concluded that association between bipolar disorder and violent crime is largely mediated by substance abuse comorbidity (Fazel et al., 2010). As our sample included only the patients with mood disorders per se, i.e. without any comorbidity, and according to the results from some previous studies (Ballester et al., 2012; Cassidy et al., 2002; Maj et al., 2003; Swann et al., 1994) where authors emphasized that hostility and aggression is assumed of particular importance as core features of manic and mixed states, we could assume that physical and verbal aggression are perhaps more related to the manic phase of illness and do not represent a stable personality trait that persists also in remission. Patients in our sample were all in euthymic phase of illness, which could explain why our results are not in line with previous studies (Ballester et al., 2012; Cassidy et al., 2002; Maj et al., 2003; Swann et al., 1994). Previous studies also suggest that 12-month diagnosis of mental disorder was generally associated with higher rates of violent behaviour than lifetime diagnosis, meaning that recent symptoms and disabilities, rather than the mere presence of the disorder, better account for violence (Corrigan and Watson, 2005). This could again explain why in our remitted sample of patients with mood disorders we did not find significant more pronounced motor component of aggression. To be able to understand the connection between aggression and different phases of illness in bipolar disorder, further studies need to be done as it could be that aggression only represents state characteristic that comes to light only in manic state of illness. As there was only one significant difference between patients with bipolar disorder and those with major depression, we further analysed the results for both groups of patients together. Our results revealed that depressive, cyclothymic, irritable and anxious temperaments are strongly intertwined and simultaneously
Table 4 Comparison of demographic, clinical and familial variables between Factor 1—prominent cyclothymic profile and Factor 2—prominent hyperthymic profile in patients with mood disorder.
Age, Mean (SD) Gender (males), N (%) Education (years), Mean (SD) Duration of illness (years), Mean (SD) Age at onset (years), Mean (SD) Diagnosis of mood disorder BD I and II, N (%) MDD, N (%) Positive family history, N (%) Current pharmacotherapy Antidepressants, N (%) Antipsychotics, N (%) Mood stabilizers, N (%) Benzodiazepines, N (%) Aggressive behaviour score. Mean (SD) Physical aggression Verbal aggression Anger Hostility
Factor 1—prominent cyclothymic profile
Factor 2—prominent hyperthymic profile
t or Chi square
p
44.04 13 12.22 7.25 39.62
40.85 17 12.80 5.52 34.18
1.35 .05 .62 1.52 2.25
ns ns ns ns o .05
(12.2) (28.9) (4.4) (4.9) (9.45)
(11.23) (30.9) (3.50) (4.44) (10.64)
22 (48.9) 23 (51.1) 15 (33.3)
32 (58.2) 23 (41.8) 15 (27.3)
.86
ns
.43
ns
26 13 17 6
(57.8) (28.9) (37.8) (13.3)
23 17 18 7
(41.8) (30.9) (32.7) (12.7)
2.52 .05 .28 .01
ns ns ns ns
15.31 13.56 20.28 23.46
(4.95) (3.71) (4.92) (6.27)
15.26 13.07 16.85 16.72
(6.82) (3.79) (5.44) (4.89)
.04 .61 3.05 5.45
ns ns o .01 o .001
B. Dolenc et al. / Journal of Affective Disorders 174 (2015) 13–18
inversely related with hyperthymic traits. This finding is consistent with several previous studies (Blöink et al., 2005; Borkowska et al., 2010; Brieger et al., 2003; Dolenc et al., 2013; Gonda et al., 2009; Perugi et al., 2012; Rózsa et al., 2008; Vázquez et al., 2007). Moreover, the factor analysis of affective temperaments revealed only two main factors. First factor again included depressive, cyclothymic, irritable and anxious traits, while the second factor consisted of hyperhymic traits. It seems that, at least from psychometrical point of view, affective temperamental dispositions are only 2 rather than 4 or 5, namely prominent cyclothymic (with dominant cyclothymic, depressive, irritable and anxious temperament) and prominent hyperthymic (with dominant hyperthymic temperament). We named these two factors according to the concept of mood reactivity, sensitivity and intensity. Factor 1 therefore represents more labile temperamental swings and prominent mood sensitivity and is characterized by emotional instability, while Factor 2 represents protuberant emotional and mood intensity (i.e. hyperthymic profile). This is again in line with several previous studies on psychometric validation of the TEMPS-A questionnaire (e.g. Akiskal et al., 2005; Borkowska et al., 2010; Rózsa et al., 2008; Vázquez et al., 2007), where authors reported only two dominant temperament types. Correlational analysis also revealed significant relationship between affective temperaments and aggressive behaviour in patients with mood disorders, which is again in line with some previous studies (Buss and Perry, 1992). Cyclothimic and irritable temperament seem to be strongly connected with all aspects of aggression, while depressive and anxious temperament proved to be positively linked only with anger and hostility, both non-motor forms of aggression. Hyperthymic temperament is connected with the verbal aggressive behaviour, while the negative connection exists between hyperthymic traits and hostility, cognitive component of aggression. Aggression and affective temperaments proved to be strongly intertwined; giving rise to a question whether genetically predisposed temperament represents one of the determinants for aggressive behaviour. Next, we compared aggressive behaviour and some with disease related variables between the two dominant factors. The results revealed that patients with prominent cyclothymic profile got their diagnosis later in their life in comparison with patients with prominent hyperthymic profile. Our results did not reveal any other demographic differences between cyclothymic and hyperthymic subtypes. Previous studies have found an overrepresentation of the female gender among cyclothymic-sensitives (Akiskal et al., 1998; Erfurth et al., 2005; Perugi et al., 1990, 2012; Signoretta et al., 2005), which our study did not confirm. Furthermore, patients with dominant Factor 1 revealed more anger and hostility related behaviour in comparison with patients with dominant Factor 2. Patients that have prominent cyclothymic temperament displayed more hostility, feelings of ill will and injustice, and more anger related emotional reactions, which involves physiological arousal and preparation for aggression (Buss and Perry, 1992). All patients were in euthymic phase of illness when assessed which could imply that anger and hostility could represent cognitive and emotional trait characteristics of prominent cyclothymic type that endure even in remission, i.e. when patients do not display depressive or (hypo)manic symptoms. It seems that distinct temperamental profile could serve as a good diagnostic and prognostic value for non-motor aspects of aggressive behaviour. Understanding aggression and its association with psychiatric disorders is of importance for a variety of reasons, especially from the standpoint of the prediction and prevention of suicidal behaviour (Feldmann, 2001). Namely, aggressive traits can increase the risk of suicidal behaviour in patients with either bipolar or major depressive disorder (Oquendo et al., 2004). Higher rates of suicide attempts exist among persons with dominant cyclothymic temperament
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(in our case, Factor 1 patients) in comparison with hyperthymic patients (Factor 2 patients) (Perugi et al., 2012) and anger-hostility as a stable trait could contribute to self-directed aggressive behaviour. Therefore it is of extreme importance for clinicians to recognize those patients' traits in time in order to prevent possible violent acts. Patients with mood disorder who have prominent cyclothymic profile seem to be characterized by affective and behavioural swings with increased mood reactivity and instability, which are accompanied with non-motor aggressive behaviour as well (anger and hostility). These patients seem to exhibit symptoms of mood disorder at earlier age in comparison with patients that have prominent hyperthymic profile (Factor 2). On the other hand, hyperthymics display less mood swings, however their behaviour and emotions are more intensely expressed. In comparison with cyclothymics, patients with more hyperthymic traits display less anger and hostility and the disease symptoms seems to manifest later in their life. 4.1. Limitations In our study, we used the results from self-report questionnaires which can sometimes elicit sociable desirable answers. The information collected was obtained only from subjects' selfevaluations and not from their relatives or clinicians, thus, the subjects could have under- or over reported their aggressive behaviour. There is a scarce of studies dealing with the relationship between affective temperaments and aggressive behaviour in patients with different mood disorders, therefore more research needs to be done to determine the diagnostic and prognostic value of different aspects of aggression, affective temperaments and mood disorders. Moreover, unresolved questions also persist about the state- versus trait- dependent nature of aggression and factors that mediate its expression in bipolar disorder and depression (Garno et al., 2008).
5. Conclusion In conclusion, our results support the view that affective temperaments influence the clinical features of mood disorders in terms of course characteristics and cognitive, emotional and behavioural features of aggression. Anger and hostility seems to represent stable personality characteristics of prominent cyclothymic profile that endure even during remission, when patients do not display depressive or (hypo)manic symptoms. This relationship between affective temperaments and aggressive behaviour highlights the contribution of genetic factors in an increased risk for violent crime, which some studies have already pointed out (Fazel et al., 2010). Early identification and treatment of mood disorder may be important to help these patients to manage their aggressiveness and avoid the development of more severe aggressive behaviours.
Role of funding source Funding for this study was provided by the Slovenian Research Agency and Astrazeneca. The Slovenian Research Agency and Astrazeneca had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Conflict of interest To the best of our knowledge, no conflict of interest is foreseeable concerning the data and results described in this article.
Acknowledgements The study has been co-founded by the Slovenian Research Agency and Astrazeneca, Projects nos. L3-9698 and P6-0347.
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References Akiskal, H.S., Akiskal, K.K., Haykal, R.F., Manning, J.S., Connor, P.D., 2005. 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. 85, 3–16. Akiskal, H.S., Djenderedjian, A.H., Resenthal, R.H., Khani, M.K., 1977. Cyclothymic disorder: validation criteria for inclusion in the bipolar affective group. Am. J. Psychiatry 134, 1227–1233. Akiskal, H.S., Hantouche, E.G., Bourgeois, M.L., Azorin, J.M., Sechter, D., Allilaire, J.F., Lancrenon, S., Fraud, J.P., Chatenet-Duchene, L., 1998. Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN). J. Affect. Disord. 50, 175–186. Akiskal, H.S., Mendlowicz, M.V., Jean-Louis, G., Rapaport, M.H., Kelsoe, J.R., Gillin, J.C., Smith, T.L., 2005. TEMPS-A: validation of a short cersion of a self-rated instrument designed to measure variations in temperament. J. Affect. Disord. 85, 45–52. Akiskal, H.S., Pinto, O., 1999. The evolving bipolar spectrum. Prototypes I, II, III, and IV. Psychiatr. Clin. N. Am. 22, 517–534. Akiskal, K.K., Akiskal, H.S., 2005. The theoretical underpinnings of affective temperaments: implications for evolutionary foundations of bipolarity and human nature. J. Affect. Disord. 85, 231–239. Ballester, J., Goldstein, T., Goldstein, B., Obreja, M., Axelson, D., Monk, K., Hickey, M., Iyengar, S., Farchione, T., Kupfer, D.J., Brent, D., Birmaher, B., 2012. Is bipolar disorder specifically associated with aggression? Bipolar Disord. 14, 283–290. Blöink, R., Brieger, P., Akiskal, H.S., Marneros, A., 2005. Factorial structure and internal consistency of the German TEMPS-A scale: validation against the NEOFFI questionnaire. J. Affect. Disord. 85, 77–83. Barlow, K., Grenyer, B., Ilkiw-Lavalle, O., 2000. Prevalence and precipitants of aggression in psychiatric inpatient units. Aust. N. Z. J. Psychiatry 34, 967–974. Brennan, P.A., Mednick, S.A., Hodgins, S., 2000. Major mental disorders and criminal violence in a Danish birth cohort. Arch. Gen. Psychiatry 57, 494–500. Brieger, P., Roettig, S., Ehrt, U., Wenzel, A., Bloink, R., Marneros, A., 2003. TEMPS-a scale in ‘mixed’ and ‘pure’ manic episodes: new data and methodological considerations on the relevance of joint anxiousdepressive temperament traits. J. Affect. Disord. 73, 99–104. Borkowska, A., Rybakowski, J.K., Drozdz, W., Bielinski, M., Kosmowska, M., Rajewska-Rager, A., Bucinski, A., Akiskal, K.K., Akiskal, H.S., 2010. Polish validation of the TEMPS-A: the profile of affective temperaments in a college student population. J. Affect. Disord. 123, 36–41. Buss, A.H., Perry, M., 1992. The aggression questionnaire. J. Pers. Soc. Psychol. 63, 452–459. Cassidy, F., Ahearn, E.P., Carroll, B.J., 2002. Symptom profile consistency in recurrent manic episodes. Compr. Psychiatry 43, 179–181. Corrigan, P.W., Watson, A.C., 2005. Findings from the National Comorbidity Survey on the frequency of violent behavior in individuals with psychiatric disorders. Psychiatry Res. 136, 153–162. Dolenc, B., Šprah, L., Dernovšek, M.Z., Akiskal, K., Akiskal, H.S., 2013. Psychometric properties of the Slovenian version of temperament evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A): temperament profiles in Slovenian university students. J. Affect. Disord. 144, 253–262. Erfurth, A., Gerlach, A.L., Michael, N., Boenigk, I., Hellweg, I., Signoretta, S., Akiskal, K., Akiskal, H.S., 2005. Distribution and gender effects of the subscales of a German version of the temperament autoquestionnaire briefTEMPS-M in a university student population. J. Affect. Disord. 85, 71–76. Faedda, G.L., Serra, G., Marangoni, C., Salvatore, P., Sani, G., Vázquez, G.H., Tondo, L., Girardi, P., Bakdessarini, R.J., Koukopoulos, A., 2014. Clinical risk factors for bipolar disorders: a systematic review of prospective studies. J. Affect. Disord. 168, 314–321. Fazel, S., Lichtenstein, P., Grann, M., Goodwin, G.M., Långström, N., 2010. Bipolar disorder and violent crime: new evidence from population-based longitudinal studies and systematic review. Arch. Gen. Psychiatry 67, 931–938. Feldmann, T.B., 2001. Bipolar disorder and violence. Psychiatr. Q. 72, 119–129. Gandotra, S., Paul, S.E., 2004. Affective temperaments and polarity in bipolar I disorder: relationship and predictive value. Hong Kong J. Psychiatry 14, 15–23. Garno, J.L., Gunawardane, N., Goldberg, J.F., 2008. Predictors of trait aggression in bipolar disorder. Bipolar Disord. 10, 285–292. Gonda, X., Fountoulakis, K.N., Rihmer, Z., Lazary, J., Laszik, A., Akiskal, K.K., Akiskal, H.S., Bagdy, G., 2009. Towards a genetically validated new affective temperament scale: a delineation of the temperament phenotype of 5-HTTLPR using the TEMPS-A. J. Affect. Disord. 112, 19–29. Graz, C., Etschel, E., Schoech, H., Soyka, M., 2009. Criminal behaviour and violent crimes in former inpatients with affective disorder. J. Affect. Disord. 117, 98–103.
Hantouche, E.G., Akiskal, H.S., Lancrenon, S., Allilaire, J.F., Sechter, D., Azorin, J.M., Bourgeois, M., Fraud, J.P., Châtenet-Duchêne, L., 1998. Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multisite study (EPIDEP). J. Affect. Disord. 50, 163–173. Harford, T.C., Yi, H.Y., Grant, B.F., 2013. Other- and self-directed forms of violence and their relationships to DSM-IV substance use and other psychiatric disorders in a national survey of adults. Compr. Psychiatry 54, 731–739. Kesic, D., Thomas, S.D.M., 2014. Do prior histories of violence and mental disorders impact on violent behaviour during encounters with police? Int. J. Law Psychiatry 37, 409–414. Latalova, K., 2009. Bipolar disorder and aggression. Int. J. Clin. Pract. 63, 889–899. Maj, M., Pirozzi, R., Magliano, L., Bartoli, L., 2003. Agitated depression in bipolar I disorder: prevalence, phenomenology, and outcome. Am. J. Psychiatry 160, 2134–2140. Matsumoto, S., Akiyama, T., Tsuda, H., Miyake, Y., Kawamura, Y., Noda, T., Akiskal, K.K., Akiskal, H.S., 2005. Reliability and validity of TEMPS-A in a Japanese non-clinical population: application to unipolar and bipolar depressives. J. Affect. Disord. 85, 85–92. Mazzarini, L., Pacchiarotti, I., Colom, F., Sani, G., Kotzalidis, G.D., Rosa, A.R., Sanna, L., De Rossi, P., Girardi, N., Bonnin, C.M., Sanchez-Moreno, J., Vazquez, G.H., Gasto, C., Tatarelli, R., Vieta, E., 2009. Predominant polarity and temperament in bipolar and unipolar affective disorders. J. Affect. Disord. 119, 28–33. Mendlowicz, M.V., Jean-Louis, G., Kelsoe, J.R., Akiskal, H.S., 2005. A comparison of recovered bipolar patients, healthy relatives of bipolar probands, and normal controls using the short TEMPS-A. J. Affect. Disord. 85, 147–151. Oquendo, M.A., Galfalvy, H., Russo, S., Ellis, S.P., Grunebaum, M.F., Burke, A., Mann, J.J., 2004. Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder. Am. J. Psychiatry 161, 1433–1441. Oquendo, M.A., Waternaux, C., Brodsky, B., Parsons, B., Haas, G.L., Malone, K.M., Mann, J.J., 2000. Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters. J. Affect. Disord. 59, 107–117. Perroud, N., Baud, P., Mouthon, D., Courtet, P., Malafosse, A., 2011. Impulsivity, aggression and suicidal behavior in unipolar and bipolar disorders. J. Affect. Disord. 134, 112–118. Perugi, G., Musetti, L., Simonini, E., Piagentini, F., Cassano, G.B., Akiskal, H.S., 1990. Gender-mediated clinical features of depressive illness. The importance of temperamental differences. Br. J. Psychiatry 157, 835–841. Perugi, G., Toni, C., Maremmani, I., Tusini, G., Ramacciotti, S., Madia, A., Fornaro, M., Akiskal, H.S., 2012. The influence of affective temperaments and psychopathological traits on the definition of bipolar disorder subtypes: a study on bipolar I Italian national sample. J. Affect. Disord. 136, 41–49. Pulay, A.J., Dawson, D.A., Hasin, D.S., Goldstein, R.B., Ruan, W.J., Pickering, R.P., Huang, B., Chou, S.P., Grant, B.F., 2008. Violent behavior and DSM-IV psychiatric disorders: results from the national epidemiologic survey on alcohol and related condition. J. Clin. Psychiatry 69, 12–22. Rózsa, S., Rihmer, Z., Gonda, X., Szili, I., Rihmer, A., Ko, N., Németh, A., Pestality, P., Bagdy, G., Alhassoon, O., Akiskal, K.K., Akiskal, H.S., 2008. A study of affective temperaments in Hungary: internal consistency and concurrent validity of the TEMPS-A against the TCI and NEO-PI-R. J. Affect. Disord. 106, 45–53. Sato, T., Bottlender, R., Sievas, M., Schröter, A., Hecht, S., Möller, H.J., 2003. Longterm inter-episode stability of syndromes underlying mania. Acta Psychiatr. Scand. 108, 310–313. Signoretta, S., Maremmani, I., Liguori, A., Perugi, G., Akiskal, H.S., 2005. Affective temperament traits measured by TEMPS-I and emotional–behavioral problems in clinically-well children, adolescents, and young adults. J. Affect. Disord. 85, 169–180. Stoddard Dare, P., Mallett, C.A., Boitel, C., 2011. Association between mental health disorders and juveniles' detention for a personal crime. Child Adolesc. Ment. Health 16, 208–213. Swann, A.C., Stokes, P.E., Secunda, S.K., Maas, J.W., Bowden, C.L., Berman, N., Koslow, S.H., 1994. Depressive mania versus agitated depression: biogenic amine and hypothalamic–pituitary–adrenocortical function. Biol. Psychiatry 35, 803–813. Vázquez, G.H., Nasetta, S., Mercado, B., Romero, E., Tifner, S., Ramón, M., del, L., Garelli, V., Bonifacio, A., Akiskal, K.K., Akiskal, H.S., 2007. Validation of the TEMPS-A Buenos Aires: Spanish psychometric validation of affective temperaments in a population study of Argentina. J. Affect. Disord. 100, 23–29. Yoon, J.H., Kim, J.H., Choi, S.S., Lyu, M.K., Kwon, J.H., Jang, Y.I., Park, G.T., 2012. Homicide and bipolar I disorder: a 22-year study. Forensic Sci. Int. 217, 113–118. Zimmermann, P., Brückl, T., Nocon, A., Pfister, H., Lieb, R., Wittchen, H.U., Holsboer, F., Angst, J., 2009. Heterogeneity of DSM-IV major depressive disorder has a consequence of sub-threshold bipolarity. Arch. Gen. Psychiatry 66, 1341–1352.
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Research report
Relationship between affective temperaments and aggression in euthymic patients with bipolar mood disorder and major depressive disorder B. Dolenc a,n, M.Z. Dernovšek b, L. Sprah a, R. Tavcar b, G. Perugi c, H.S. Akiskal d a
Sociomedical Institute, Research Centre of the Slovenian Academy of Sciences and Arts, Ljubljana, Slovenia University Psychiatric Clinic, Ljubljana, Slovenia c Institute of Behavioural Sciences, “G. De Lisio”, Department of Psychiatry, University of Pisa, Pisa, Italy d International Mood Disorder Centre, Department of Psychiatry at the University of California, San Diego, La Jolla, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 30 June 2014 Received in revised form 9 October 2014 Accepted 8 November 2014 Available online 20 November 2014
Background: So far there is a scarce of studies dealing with the relationship between different aspects of aggressive behaviour and affective temperaments among various mood disorders. The aim of the present study was to explore in a group of patients with affective mood disorders the relationship between affective temperaments and aggression. Methods: 100 consecutive outpatients in euthymic phase of mood disorders (46 with bipolar disorder— type I, 18 with bipolar disorder—type II and 36 with major depressive disorder) were self-assessed with the Aggression Questionnaire and the short version of Slovenian Temperament Evaluation of Memphis, Pisa, Paris and San Diego – Autoquestionnaire (TEMPS-A). Results: The factorial analysis of the TEMPS-A subscales revealed 2 main factors: Factor 1 (prominent cyclothymic profile) consisted of cyclothymic, depressive, irritable, and anxious temperaments and Factor 2 (prominent hyperthymic profile) which was represented by the hyperthymic temperament, and by depressive and anxious temperaments as negative components. Patients with prominent cyclothymic profile got their diagnosis later in their life and had significantly higher mean scores on anger and hostility (non-motor aggressive behaviour) compared with patients with prominent hyperthymic profile. Limitations: We included patients with different mood disorders, therefore the sample selection may influence temperamental and aggression profiles. We used self-report questionnaires which can elicit sociable desirable answers. Conclusion: Anger and hostility could represent stable personality characteristics of prominent cyclothymic profile that endure even in remission. It seems that distinct temperamental profile could serve as a good diagnostic and prognostic value for non-motor aspects of aggressive behaviour. & 2014 Elsevier B.V. All rights reserved.
Keywords: Affective temperament Aggression Bipolar disorder Major depressive disorder
1. Introduction Several psychiatric disorders, including mood disorders, have been associated with increased rates of aggression and violent behaviour (Ballester et al., 2012; Brennan et al., 2000; Corrigan and Watson, 2005; Faedda et al., 2014; Feldmann, 2001; Harford et al., 2013; Oquendo et al., 2000), which could also carry diagnostic, prognostic, and therapeutic implications. However, the evidence for interpersonal violence and violent crime in patients with bipolar disorder is less clear (Fazel et al., 2010). Perroud et al. (2011) report that patients with bipolar and major depressive disorders display more frequent and severe lifetime
n
Corresponding author. Tel.: þ 386 41 374 078. E-mail address: [email protected] (B. Dolenc).
http://dx.doi.org/10.1016/j.jad.2014.11.007 0165-0327/& 2014 Elsevier B.V. All rights reserved.
aggressive behaviours than healthy persons. Some data also indicate a higher criminality rate in bipolar patients in comparison with patients with unipolar major depression (Cassidy et al., 2002; Corrigan and Watson, 2005; Graz et al., 2009; Sato et al., 2003). A significant association was reported between criminal behaviours and sub-threshold and syndromal bipolar disorder (Zimmermann et al., 2009). Barlow et al. (2000) report that patients with bipolar disorder express more aggressive behaviour in comparison with patients with other Axis-I disorders. Retrospectively assessed violent behaviour before and after the age of 15 is also reported to be associated with bipolar disorder (Pulay et al., 2008). Some studies also revealed that the diagnosis of bipolar disorder significantly increased the likelihood of being incarcerated (Stoddard Dare et al., 2011). In the case of bipolar disorder, the National Comorbidity Survey showed that the 12-month adult population prevalence of violent behaviours was 2%, whereas it was 16% for adults with bipolar disorder (Corrigan and
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Watson, 2005). Corrigan and Watson (2005) report that for patients with bipolar disorder the odds ratio for violence is 9.5 higher in comparison with healthy controls, meaning that people with bipolar disorder will have a 9.5 times greater likelihood of reporting violent behaviours than those with no mental disorder. However, some authors report that self-directed violence is more strongly associated with mood disorder compared with other-directed violence (Harford et al., 2013). In a longitudinal study of individuals with bipolar disorder, Fazel et al. (2010) reported that there was an increased risk for violent crime among individuals with bipolar disorder, but most of the excess violent crime was associated with substance abuse comorbidity, whereas the risk associated with a bipolar disorder per se appeared low. Authors concluded that the association between bipolar disorder and violent crime seems to be largely mediated by substance abuse comorbidity. Some studies also revealed, that violent behaviour is associated particularly during mania, mixed episodes, or psychotic states (Latalova, 2009), whereas hostility and aggression have been assumed of particular importance as core features of manic and mixed states (Cassidy et al., 2002; Maj et al., 2003; Swann et al., 1994). Some authors report that the general rate of total offence is higher in the manic phase of bipolar disorder in comparison with the depressive phase, whereas the rate of homicide is higher in the depressive phase of bipolar disorder (Yoon et al., 2012). Corrigan and Watson (2005) also pointed out that when adjusting violence rates by population base rates, demographics including ethnicity and gender revealed to be a better predictor of violent behaviour than psychiatric diagnosis, leading to a conclusion that mental illness is only a weak predictor of violent behaviour. Kesic and Thomas (2014) also reported that having a history of prior mental disorder diagnoses is not associated with violence which again challenges the traditional stereotyped view about the violence risk posed by people with prior contact with mental health services. Different conclusions made by previous studies show that more research needs to be done on explaining the relationship between mental illness and violent behaviour. It could be that research summaries that stress the connection of violence and psychiatric disorder may be exacerbating the stigma of mental illness (Corrigan and Watson, 2005). Besides aggressive traits, affective temperament supposed to have an impact on the clinical manifestation of mood disorders and on their course as well (Akiskal and Akiskal, 2005; Akiskal et al., 1977, Hantouche et al., 1998). Akiskal et al. (1977) postulated that temperament could represent the earliest subclinical phenotype of mood disorders and could be a potential contributor to the bipolar spectrum (Akiskal and Pinto, 1999). Numerous studies reported of specific temperament profile in patients with bipolar disorder (Hantouche et al., 1998; Matsumoto et al., 2005; Mazzarini et al., 2009; Mendlowicz et al., 2005) and major depression (Matsumoto et al., 2005; Mazzarini et al., 2009). However the predictive value of affective temperaments on the outcome of the bipolar disorder still requires further research (Perugi et al., 2012). The intertwinement between temperament and aggressive behaviour has been known for several years (e.g. Buss and Perry, 1992). However, so far there is a scarce of studies dealing with different aspects of aggressive behaviour among various affective disorders (Brennan et al., 2000; Graz et al., 2009). Some studies show that there is an increased risk for violent crime among the unaffected siblings of individuals with bipolar disorder, which further weakens the relationship between bipolar disorder per se and violent crime and highlights the contribution of genetic or early environmental factors in families with bipolar disorder (Fazel et al., 2010). From this standpoint, the role of affective temperaments in violent behaviour in mood disorders comes even more to the front.
It is crucial to understand the relationship between affective mood disorders and aggressive behaviour together with temperamental traits as these violent behaviours are associated with an increased risk for individual and familial suffering, socioeconomic and legal problems (Ballester et al., 2012) and also with the suicidal risk (Oquendo et al., 2004). Specifically, it has been recognized that behavioural dysregulation characterizes suicidal behaviour with aggression being particularly salient (Oquendo et al., 2004; Perroud et al., 2011). Unresolved questions also persist about the state- versus trait- dependent nature of aggression and factors that mediate its expression in bipolar disorder and depression (Garno et al., 2008). The aim of the present study was to explore in a group of patients with mood disorders (bipolar disorder—type I, bipolar disorder—type II and Major Depressive Disorder), evaluated in euthymic phase of illness, the relationship between affective temperaments and aggression. We focused on the influence of affective temperament as a relatively stable trait (Gandotra and Paul, 2004) on different disease-related variables and different aspects of aggressive behaviour.
2. Methods 2.1. Subjects 100 consecutive outpatients with mood disorders were included in our study. The sample comprised of 64 (64%) patients with bipolar disorder (of that 46 with bipolar disorder—type I [BD I] and 18 patients with bipolar disorder—type II [BD II]) and 36 (36%) patients with major depressive disorder (MDD). 30 (30%) patients were males and 70 (70%) females. All patients were in euthymic phase of illness, according to ICD-10 diagnostic criteria. All patients were treated as outpatients in University Psychiatric Clinic Ljubljana in the year 2012. All patients were treated in full accordance with the routine clinical practice. The efficacy and the effectiveness of the treatments were not among the aims of the investigation. All subjects who were not in a stable mental or physical condition due to any cause, subjects who were not for 6 months in stable remission according to the case records, subjects with other psychiatric diagnoses, pregnant women, subjects already enrolled in other studies and subjects who were unable to give an informed consent were excluded from the study. All subjects included in our study gave written informed consent and had the chance to give up the study at any time.
2.2. Measures Two self-assessment questionnaires were used in our study. The Aggression Questionnaire (Buss and Perry, 1992) is constructed of four aggression subscales: physical aggression (hurting or harming others —instrumental or motor component of behaviour), verbal aggression (hurting or harming others—instrumental or motor component of behaviour), anger (physiological arousal and preparation for aggression—emotional or affective component of behaviour), and hostility (feelings of ill will and injustice—cognitive component of behaviour). The short version of Slovenian TEMPS-A Scale (Temperament Evaluation of Memphis, Pisa, Paris and San Diego – Autoquestionnaire, Akiskal et al., 2005) was used to measure five affective temperaments, namely depressive (increased sensitivity to life's sorrows and disappointments), cyclothymic (labile mood swings), hyperthymic (enterprising, ambitious and driven), irritable (angry and dissatisfied) and anxious (prone to worrying and anxiety).
B. Dolenc et al. / Journal of Affective Disorders 174 (2015) 13–18
2.3. Procedure The study was cross sectional. First, the state affectivity and all comorbid disorders in subjects with the history of mood disorder was clinically stated and confirmed by studying the case file by an experienced clinician. All patients who were not in euthymic phase of illness for at least 6 months, subjects with other psychiatric diagnoses (comorbid disorders), pregnant women and subject, who were already enrolled in other research projects, were excluded from our study. Subjects, who were in a stable remission phase and who had only diagnosis of affective mood disorders were further invited to participate in our research as studies show that self-reports of violent behaviour are much more frequent in people with more than one co-occurring disorder (Corrigan and Watson, 2005; Fazel et al., 2010). After explaining the patients the aim of the study, subjects gave informed consent. During the clinical interview information on demographic data, diagnostic and clinical features (comorbidity), as well as data on disease course and family history were collected. Lastly, the selfevaluations of temperamental and aggressive behaviour were conducted. The interview and filling out the questionnaires demanded about 1.5 h per subject. The study was approved by the National medical ethics committee. 2.4. Statistical analyses For all subjects, means of item sums for affective temperament subscales measured by TEMPS-A and Aggression Questionnaire subscales were calculated. We calculated differences in those scores between both groups of patients with t-test for independent samples. Next, the relationship between different affective temperaments and four types of aggressive behaviour has been examined and tested with Pearson's correlation coefficients. In Table 1 Means and standard deviations (in parenthesis) of the five subscales' sums from TEMPS-A (depressive, hyperthymic, cyclothymic, irritable and anxious subscale) and four subscales from Aggression Questionnaire (physical aggression, verbal aggression, anger and hostility subscale) for patients with MDD and BD I and II in remission. N¼ 100.
Depressive Cyclothymic Hyperthymic Irritable Anxious Physical aggression Verbal aggression Anger Hostility
MDD
BD I and II
t
p
2.9 3.8 4.4 2.5 3.9 14.8 13.4 17.2 19.9
3.6 4.3 4.5 2.7 4.7 15.8 13.2 19.8 19.6
1.07 .89 .09 .61 1.68 .78 .27 2.20 .216
ns ns ns ns ns ns ns .030 ns
(2.9) (2.8) (2.6) (2.4) (2.6) (5.8) (4.3) (5.9) (6.7)
(2.9) (2.2) (2.6) (2.1) (2.3) (6.2) (3.1) (4.6) (6.3)
15
order to detect possible composite dimensions of different affective temperaments, a factorial analysis was performed on the TEMPS-A subscales. The initial factors were extracted by means of principal component analysis and then rotated according to Oblimin oblique rotation. Subjects' scores were then grouped into two dominant temperaments (according to factor analysis). To evaluate the differences in two dominant factors, the t-test and Chi-square test were used for the analyses of differences in several demographic and disease related variables between both groups of dominant temperament, respectively. P values lower than.05 were considered statistically significant. All statistical analyses were done with SPSS 20.0.
3. Results First, we calculated the differences between both groups of patients between affective temperaments and aggressive behaviour (Table 1). The mean scores of affective temperaments subscales' sums in TEMPS-A were the highest for hyperthymic, cyclothymic and anxious temperaments in both groups of patients, and the lowest for depressive and irritable temperaments. There were no statistically significant differences between both groups of patients. The mean scores of subscales' sums in Aggression Questionnaire were the highest for anger and hostility and the lowest for verbal aggression in both groups of patients. With the exception of the difference in mean scores of sums in anger no other statistically significant differences between MDD and BP I and II patients were found. Therefore we present the results for both groups together. Significant relationship between different affective temperaments exists (see Table 2). The score of depressive temperament was positively correlated with the scores of cyclothymic, irritable and anxious temperament and negatively with hyperthymic temperament. The score of cyclothymic temperament was positively correlated with the scores of depressive, irritable and anxious temperaments and negatively with hyperthymic temperament. The score of hyperthymic temperament was negatively correlated with all four temperaments, with the exception of the irritable temperament, where the correlation was not statistically significant. The score of irritable temperament was positively correlated with the scores of depressive, cyclothymic and anxious temperament. The score of anxious temperament was positively correlated with the scores of depressive, cyclothymic and irritable temperaments and negatively correlated with the score of hyperthymic temperament. There are many statistically significant correlations between scores on TEMPS-A subscales and scores on subscales of Aggression Questionnaire as well. The scores of cyclothymic and irritable temperament were positively correlated with all four scores of
Table 2 Pearson's correlation coefficients among affective temperament as measured by TEMPS-A (depressive, hyperthymic, cyclothymic, irritable and anxious subscale) and four subscales from Aggression Questionnaire (physical aggression, verbal aggression, anger and hostility subscale) for patients with mood disorder in remission. N ¼ 100.
Cyclothymic Hyperthymic Irritable Anxious Physical aggression Verbal aggression Anger Hostility n
po .05. p o.01.
nn
Depressive
Cyclothymic
Hyperthymic
Irritable
Anxious
Physical aggression
Verbal aggression
Anger
.70nn .43nn .49nn .52nn .10 .05 .32nn .51nn
– .24n .59nn .57nn .23n .27n .52nn .60nn
– .01 .32nn .16 .25n .02 .28nn
– .33nn .63nn .54nn .59nn .49nn
– .10 .09 .43nn .54nn
– .49nn .55nn .31nn
– .59nn .50nn
– .51nn
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Aggression Questionnaire. Depressive and anxious temperaments were positively correlated only with anger and hostility. Hyperthymic temperament was positively correlated with scores of verbal aggression and negatively correlated with the scores of hostility. Next, we conducted factor analysis to determine possible composite dimensions of affective temperaments (see Tables 3 and 4). Because of the high correlations between all the affective temperaments (see Table 2), we conducted a factor analysis with Oblimin oblique rotation. The factorial analysis of the mean scores of sums of the TEMPSA subscales showed 2 main factors in patients with mood disorders. Both factors explained 76% of the total variance. The first factor (55.39% of the variance) consisted of cyclothymic, depressive, irritable, and anxious temperament. The second factor (20.74% of variance) was represented by the hyperthymic temperament as the only positive component, and by depressive and anxious temperaments as negative components. We named these two factors according to the concept of mood reactivity, sensitivity and intensity as prominent cyclothymic and prominent hyperthymic, respectively. Factor 1 represents temperaments with prominent mood reactivity and sensitivity (prominent cyclothymic profile) and Factor 2 represents prominent mood intensity (prominent hyperthymic profile).
4. Discussion The aim of the present study was to explore in a group of patients with mood disorders (bipolar disorder—type I, bipolar Table 3 Factorial analysis (PCA extraction, Oblimin rotation) of TEMPS-A depressive, hyperthymic, cyclothymic, irritable and anxious subscale scores in patients with mood disorder in remission. Factor 1—prominent cyclothymic profile Depressive .82 Cyclothymic .89 Hyperthymic .24 Irritable .80 Anxious .69 Eigenvalue 2.77 % of variance 55.39
Factor 2—prominent hyperthymic profile .47 .23 .93 .19 .47 1.04 20.74
disorder—type II and Major Depressive Disorder) the relationship between affective temperaments and different aspects of aggressive behaviour. Temperament represents a relatively stable trait (Gandotra and Paul, 2004), therefore we focused on its influence on aggression and different variables related to mood disorders. First, we analysed the differences in affective temperaments and aggressive behaviour between patients with bipolar disorder and patients with major depressive disorder. Both groups of patients differed only in anger, whereas all the other differences were not significant. Previous studies report higher aggressive behaviour and criminality rate especially in the manic episode of bipolar disorder (Cassidy et al., 2002; Maj et al., 2003; Swann et al., 1994), whereas some authors concluded that association between bipolar disorder and violent crime is largely mediated by substance abuse comorbidity (Fazel et al., 2010). As our sample included only the patients with mood disorders per se, i.e. without any comorbidity, and according to the results from some previous studies (Ballester et al., 2012; Cassidy et al., 2002; Maj et al., 2003; Swann et al., 1994) where authors emphasized that hostility and aggression is assumed of particular importance as core features of manic and mixed states, we could assume that physical and verbal aggression are perhaps more related to the manic phase of illness and do not represent a stable personality trait that persists also in remission. Patients in our sample were all in euthymic phase of illness, which could explain why our results are not in line with previous studies (Ballester et al., 2012; Cassidy et al., 2002; Maj et al., 2003; Swann et al., 1994). Previous studies also suggest that 12-month diagnosis of mental disorder was generally associated with higher rates of violent behaviour than lifetime diagnosis, meaning that recent symptoms and disabilities, rather than the mere presence of the disorder, better account for violence (Corrigan and Watson, 2005). This could again explain why in our remitted sample of patients with mood disorders we did not find significant more pronounced motor component of aggression. To be able to understand the connection between aggression and different phases of illness in bipolar disorder, further studies need to be done as it could be that aggression only represents state characteristic that comes to light only in manic state of illness. As there was only one significant difference between patients with bipolar disorder and those with major depression, we further analysed the results for both groups of patients together. Our results revealed that depressive, cyclothymic, irritable and anxious temperaments are strongly intertwined and simultaneously
Table 4 Comparison of demographic, clinical and familial variables between Factor 1—prominent cyclothymic profile and Factor 2—prominent hyperthymic profile in patients with mood disorder.
Age, Mean (SD) Gender (males), N (%) Education (years), Mean (SD) Duration of illness (years), Mean (SD) Age at onset (years), Mean (SD) Diagnosis of mood disorder BD I and II, N (%) MDD, N (%) Positive family history, N (%) Current pharmacotherapy Antidepressants, N (%) Antipsychotics, N (%) Mood stabilizers, N (%) Benzodiazepines, N (%) Aggressive behaviour score. Mean (SD) Physical aggression Verbal aggression Anger Hostility
Factor 1—prominent cyclothymic profile
Factor 2—prominent hyperthymic profile
t or Chi square
p
44.04 13 12.22 7.25 39.62
40.85 17 12.80 5.52 34.18
1.35 .05 .62 1.52 2.25
ns ns ns ns o .05
(12.2) (28.9) (4.4) (4.9) (9.45)
(11.23) (30.9) (3.50) (4.44) (10.64)
22 (48.9) 23 (51.1) 15 (33.3)
32 (58.2) 23 (41.8) 15 (27.3)
.86
ns
.43
ns
26 13 17 6
(57.8) (28.9) (37.8) (13.3)
23 17 18 7
(41.8) (30.9) (32.7) (12.7)
2.52 .05 .28 .01
ns ns ns ns
15.31 13.56 20.28 23.46
(4.95) (3.71) (4.92) (6.27)
15.26 13.07 16.85 16.72
(6.82) (3.79) (5.44) (4.89)
.04 .61 3.05 5.45
ns ns o .01 o .001
B. Dolenc et al. / Journal of Affective Disorders 174 (2015) 13–18
inversely related with hyperthymic traits. This finding is consistent with several previous studies (Blöink et al., 2005; Borkowska et al., 2010; Brieger et al., 2003; Dolenc et al., 2013; Gonda et al., 2009; Perugi et al., 2012; Rózsa et al., 2008; Vázquez et al., 2007). Moreover, the factor analysis of affective temperaments revealed only two main factors. First factor again included depressive, cyclothymic, irritable and anxious traits, while the second factor consisted of hyperhymic traits. It seems that, at least from psychometrical point of view, affective temperamental dispositions are only 2 rather than 4 or 5, namely prominent cyclothymic (with dominant cyclothymic, depressive, irritable and anxious temperament) and prominent hyperthymic (with dominant hyperthymic temperament). We named these two factors according to the concept of mood reactivity, sensitivity and intensity. Factor 1 therefore represents more labile temperamental swings and prominent mood sensitivity and is characterized by emotional instability, while Factor 2 represents protuberant emotional and mood intensity (i.e. hyperthymic profile). This is again in line with several previous studies on psychometric validation of the TEMPS-A questionnaire (e.g. Akiskal et al., 2005; Borkowska et al., 2010; Rózsa et al., 2008; Vázquez et al., 2007), where authors reported only two dominant temperament types. Correlational analysis also revealed significant relationship between affective temperaments and aggressive behaviour in patients with mood disorders, which is again in line with some previous studies (Buss and Perry, 1992). Cyclothimic and irritable temperament seem to be strongly connected with all aspects of aggression, while depressive and anxious temperament proved to be positively linked only with anger and hostility, both non-motor forms of aggression. Hyperthymic temperament is connected with the verbal aggressive behaviour, while the negative connection exists between hyperthymic traits and hostility, cognitive component of aggression. Aggression and affective temperaments proved to be strongly intertwined; giving rise to a question whether genetically predisposed temperament represents one of the determinants for aggressive behaviour. Next, we compared aggressive behaviour and some with disease related variables between the two dominant factors. The results revealed that patients with prominent cyclothymic profile got their diagnosis later in their life in comparison with patients with prominent hyperthymic profile. Our results did not reveal any other demographic differences between cyclothymic and hyperthymic subtypes. Previous studies have found an overrepresentation of the female gender among cyclothymic-sensitives (Akiskal et al., 1998; Erfurth et al., 2005; Perugi et al., 1990, 2012; Signoretta et al., 2005), which our study did not confirm. Furthermore, patients with dominant Factor 1 revealed more anger and hostility related behaviour in comparison with patients with dominant Factor 2. Patients that have prominent cyclothymic temperament displayed more hostility, feelings of ill will and injustice, and more anger related emotional reactions, which involves physiological arousal and preparation for aggression (Buss and Perry, 1992). All patients were in euthymic phase of illness when assessed which could imply that anger and hostility could represent cognitive and emotional trait characteristics of prominent cyclothymic type that endure even in remission, i.e. when patients do not display depressive or (hypo)manic symptoms. It seems that distinct temperamental profile could serve as a good diagnostic and prognostic value for non-motor aspects of aggressive behaviour. Understanding aggression and its association with psychiatric disorders is of importance for a variety of reasons, especially from the standpoint of the prediction and prevention of suicidal behaviour (Feldmann, 2001). Namely, aggressive traits can increase the risk of suicidal behaviour in patients with either bipolar or major depressive disorder (Oquendo et al., 2004). Higher rates of suicide attempts exist among persons with dominant cyclothymic temperament
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(in our case, Factor 1 patients) in comparison with hyperthymic patients (Factor 2 patients) (Perugi et al., 2012) and anger-hostility as a stable trait could contribute to self-directed aggressive behaviour. Therefore it is of extreme importance for clinicians to recognize those patients' traits in time in order to prevent possible violent acts. Patients with mood disorder who have prominent cyclothymic profile seem to be characterized by affective and behavioural swings with increased mood reactivity and instability, which are accompanied with non-motor aggressive behaviour as well (anger and hostility). These patients seem to exhibit symptoms of mood disorder at earlier age in comparison with patients that have prominent hyperthymic profile (Factor 2). On the other hand, hyperthymics display less mood swings, however their behaviour and emotions are more intensely expressed. In comparison with cyclothymics, patients with more hyperthymic traits display less anger and hostility and the disease symptoms seems to manifest later in their life. 4.1. Limitations In our study, we used the results from self-report questionnaires which can sometimes elicit sociable desirable answers. The information collected was obtained only from subjects' selfevaluations and not from their relatives or clinicians, thus, the subjects could have under- or over reported their aggressive behaviour. There is a scarce of studies dealing with the relationship between affective temperaments and aggressive behaviour in patients with different mood disorders, therefore more research needs to be done to determine the diagnostic and prognostic value of different aspects of aggression, affective temperaments and mood disorders. Moreover, unresolved questions also persist about the state- versus trait- dependent nature of aggression and factors that mediate its expression in bipolar disorder and depression (Garno et al., 2008).
5. Conclusion In conclusion, our results support the view that affective temperaments influence the clinical features of mood disorders in terms of course characteristics and cognitive, emotional and behavioural features of aggression. Anger and hostility seems to represent stable personality characteristics of prominent cyclothymic profile that endure even during remission, when patients do not display depressive or (hypo)manic symptoms. This relationship between affective temperaments and aggressive behaviour highlights the contribution of genetic factors in an increased risk for violent crime, which some studies have already pointed out (Fazel et al., 2010). Early identification and treatment of mood disorder may be important to help these patients to manage their aggressiveness and avoid the development of more severe aggressive behaviours.
Role of funding source Funding for this study was provided by the Slovenian Research Agency and Astrazeneca. The Slovenian Research Agency and Astrazeneca had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Conflict of interest To the best of our knowledge, no conflict of interest is foreseeable concerning the data and results described in this article.
Acknowledgements The study has been co-founded by the Slovenian Research Agency and Astrazeneca, Projects nos. L3-9698 and P6-0347.
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B. Dolenc et al. / Journal of Affective Disorders 174 (2015) 13–18
References Akiskal, H.S., Akiskal, K.K., Haykal, R.F., Manning, J.S., Connor, P.D., 2005. 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. 85, 3–16. Akiskal, H.S., Djenderedjian, A.H., Resenthal, R.H., Khani, M.K., 1977. Cyclothymic disorder: validation criteria for inclusion in the bipolar affective group. Am. J. Psychiatry 134, 1227–1233. Akiskal, H.S., Hantouche, E.G., Bourgeois, M.L., Azorin, J.M., Sechter, D., Allilaire, J.F., Lancrenon, S., Fraud, J.P., Chatenet-Duchene, L., 1998. Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN). J. Affect. Disord. 50, 175–186. Akiskal, H.S., Mendlowicz, M.V., Jean-Louis, G., Rapaport, M.H., Kelsoe, J.R., Gillin, J.C., Smith, T.L., 2005. TEMPS-A: validation of a short cersion of a self-rated instrument designed to measure variations in temperament. J. Affect. Disord. 85, 45–52. Akiskal, H.S., Pinto, O., 1999. The evolving bipolar spectrum. Prototypes I, II, III, and IV. Psychiatr. Clin. N. Am. 22, 517–534. Akiskal, K.K., Akiskal, H.S., 2005. The theoretical underpinnings of affective temperaments: implications for evolutionary foundations of bipolarity and human nature. J. Affect. Disord. 85, 231–239. Ballester, J., Goldstein, T., Goldstein, B., Obreja, M., Axelson, D., Monk, K., Hickey, M., Iyengar, S., Farchione, T., Kupfer, D.J., Brent, D., Birmaher, B., 2012. Is bipolar disorder specifically associated with aggression? Bipolar Disord. 14, 283–290. Blöink, R., Brieger, P., Akiskal, H.S., Marneros, A., 2005. Factorial structure and internal consistency of the German TEMPS-A scale: validation against the NEOFFI questionnaire. J. Affect. Disord. 85, 77–83. Barlow, K., Grenyer, B., Ilkiw-Lavalle, O., 2000. Prevalence and precipitants of aggression in psychiatric inpatient units. Aust. N. Z. J. Psychiatry 34, 967–974. Brennan, P.A., Mednick, S.A., Hodgins, S., 2000. Major mental disorders and criminal violence in a Danish birth cohort. Arch. Gen. Psychiatry 57, 494–500. Brieger, P., Roettig, S., Ehrt, U., Wenzel, A., Bloink, R., Marneros, A., 2003. TEMPS-a scale in ‘mixed’ and ‘pure’ manic episodes: new data and methodological considerations on the relevance of joint anxiousdepressive temperament traits. J. Affect. Disord. 73, 99–104. Borkowska, A., Rybakowski, J.K., Drozdz, W., Bielinski, M., Kosmowska, M., Rajewska-Rager, A., Bucinski, A., Akiskal, K.K., Akiskal, H.S., 2010. Polish validation of the TEMPS-A: the profile of affective temperaments in a college student population. J. Affect. Disord. 123, 36–41. Buss, A.H., Perry, M., 1992. The aggression questionnaire. J. Pers. Soc. Psychol. 63, 452–459. Cassidy, F., Ahearn, E.P., Carroll, B.J., 2002. Symptom profile consistency in recurrent manic episodes. Compr. Psychiatry 43, 179–181. Corrigan, P.W., Watson, A.C., 2005. Findings from the National Comorbidity Survey on the frequency of violent behavior in individuals with psychiatric disorders. Psychiatry Res. 136, 153–162. Dolenc, B., Šprah, L., Dernovšek, M.Z., Akiskal, K., Akiskal, H.S., 2013. Psychometric properties of the Slovenian version of temperament evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A): temperament profiles in Slovenian university students. J. Affect. Disord. 144, 253–262. Erfurth, A., Gerlach, A.L., Michael, N., Boenigk, I., Hellweg, I., Signoretta, S., Akiskal, K., Akiskal, H.S., 2005. Distribution and gender effects of the subscales of a German version of the temperament autoquestionnaire briefTEMPS-M in a university student population. J. Affect. Disord. 85, 71–76. Faedda, G.L., Serra, G., Marangoni, C., Salvatore, P., Sani, G., Vázquez, G.H., Tondo, L., Girardi, P., Bakdessarini, R.J., Koukopoulos, A., 2014. Clinical risk factors for bipolar disorders: a systematic review of prospective studies. J. Affect. Disord. 168, 314–321. Fazel, S., Lichtenstein, P., Grann, M., Goodwin, G.M., Långström, N., 2010. Bipolar disorder and violent crime: new evidence from population-based longitudinal studies and systematic review. Arch. Gen. Psychiatry 67, 931–938. Feldmann, T.B., 2001. Bipolar disorder and violence. Psychiatr. Q. 72, 119–129. Gandotra, S., Paul, S.E., 2004. Affective temperaments and polarity in bipolar I disorder: relationship and predictive value. Hong Kong J. Psychiatry 14, 15–23. Garno, J.L., Gunawardane, N., Goldberg, J.F., 2008. Predictors of trait aggression in bipolar disorder. Bipolar Disord. 10, 285–292. Gonda, X., Fountoulakis, K.N., Rihmer, Z., Lazary, J., Laszik, A., Akiskal, K.K., Akiskal, H.S., Bagdy, G., 2009. Towards a genetically validated new affective temperament scale: a delineation of the temperament phenotype of 5-HTTLPR using the TEMPS-A. J. Affect. Disord. 112, 19–29. Graz, C., Etschel, E., Schoech, H., Soyka, M., 2009. Criminal behaviour and violent crimes in former inpatients with affective disorder. J. Affect. Disord. 117, 98–103.
Hantouche, E.G., Akiskal, H.S., Lancrenon, S., Allilaire, J.F., Sechter, D., Azorin, J.M., Bourgeois, M., Fraud, J.P., Châtenet-Duchêne, L., 1998. Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multisite study (EPIDEP). J. Affect. Disord. 50, 163–173. Harford, T.C., Yi, H.Y., Grant, B.F., 2013. Other- and self-directed forms of violence and their relationships to DSM-IV substance use and other psychiatric disorders in a national survey of adults. Compr. Psychiatry 54, 731–739. Kesic, D., Thomas, S.D.M., 2014. Do prior histories of violence and mental disorders impact on violent behaviour during encounters with police? Int. J. Law Psychiatry 37, 409–414. Latalova, K., 2009. Bipolar disorder and aggression. Int. J. Clin. Pract. 63, 889–899. Maj, M., Pirozzi, R., Magliano, L., Bartoli, L., 2003. Agitated depression in bipolar I disorder: prevalence, phenomenology, and outcome. Am. J. Psychiatry 160, 2134–2140. Matsumoto, S., Akiyama, T., Tsuda, H., Miyake, Y., Kawamura, Y., Noda, T., Akiskal, K.K., Akiskal, H.S., 2005. Reliability and validity of TEMPS-A in a Japanese non-clinical population: application to unipolar and bipolar depressives. J. Affect. Disord. 85, 85–92. Mazzarini, L., Pacchiarotti, I., Colom, F., Sani, G., Kotzalidis, G.D., Rosa, A.R., Sanna, L., De Rossi, P., Girardi, N., Bonnin, C.M., Sanchez-Moreno, J., Vazquez, G.H., Gasto, C., Tatarelli, R., Vieta, E., 2009. Predominant polarity and temperament in bipolar and unipolar affective disorders. J. Affect. Disord. 119, 28–33. Mendlowicz, M.V., Jean-Louis, G., Kelsoe, J.R., Akiskal, H.S., 2005. A comparison of recovered bipolar patients, healthy relatives of bipolar probands, and normal controls using the short TEMPS-A. J. Affect. Disord. 85, 147–151. Oquendo, M.A., Galfalvy, H., Russo, S., Ellis, S.P., Grunebaum, M.F., Burke, A., Mann, J.J., 2004. Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder. Am. J. Psychiatry 161, 1433–1441. Oquendo, M.A., Waternaux, C., Brodsky, B., Parsons, B., Haas, G.L., Malone, K.M., Mann, J.J., 2000. Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters. J. Affect. Disord. 59, 107–117. Perroud, N., Baud, P., Mouthon, D., Courtet, P., Malafosse, A., 2011. Impulsivity, aggression and suicidal behavior in unipolar and bipolar disorders. J. Affect. Disord. 134, 112–118. Perugi, G., Musetti, L., Simonini, E., Piagentini, F., Cassano, G.B., Akiskal, H.S., 1990. Gender-mediated clinical features of depressive illness. The importance of temperamental differences. Br. J. Psychiatry 157, 835–841. Perugi, G., Toni, C., Maremmani, I., Tusini, G., Ramacciotti, S., Madia, A., Fornaro, M., Akiskal, H.S., 2012. The influence of affective temperaments and psychopathological traits on the definition of bipolar disorder subtypes: a study on bipolar I Italian national sample. J. Affect. Disord. 136, 41–49. Pulay, A.J., Dawson, D.A., Hasin, D.S., Goldstein, R.B., Ruan, W.J., Pickering, R.P., Huang, B., Chou, S.P., Grant, B.F., 2008. Violent behavior and DSM-IV psychiatric disorders: results from the national epidemiologic survey on alcohol and related condition. J. Clin. Psychiatry 69, 12–22. Rózsa, S., Rihmer, Z., Gonda, X., Szili, I., Rihmer, A., Ko, N., Németh, A., Pestality, P., Bagdy, G., Alhassoon, O., Akiskal, K.K., Akiskal, H.S., 2008. A study of affective temperaments in Hungary: internal consistency and concurrent validity of the TEMPS-A against the TCI and NEO-PI-R. J. Affect. Disord. 106, 45–53. Sato, T., Bottlender, R., Sievas, M., Schröter, A., Hecht, S., Möller, H.J., 2003. Longterm inter-episode stability of syndromes underlying mania. Acta Psychiatr. Scand. 108, 310–313. Signoretta, S., Maremmani, I., Liguori, A., Perugi, G., Akiskal, H.S., 2005. Affective temperament traits measured by TEMPS-I and emotional–behavioral problems in clinically-well children, adolescents, and young adults. J. Affect. Disord. 85, 169–180. Stoddard Dare, P., Mallett, C.A., Boitel, C., 2011. Association between mental health disorders and juveniles' detention for a personal crime. Child Adolesc. Ment. Health 16, 208–213. Swann, A.C., Stokes, P.E., Secunda, S.K., Maas, J.W., Bowden, C.L., Berman, N., Koslow, S.H., 1994. Depressive mania versus agitated depression: biogenic amine and hypothalamic–pituitary–adrenocortical function. Biol. Psychiatry 35, 803–813. Vázquez, G.H., Nasetta, S., Mercado, B., Romero, E., Tifner, S., Ramón, M., del, L., Garelli, V., Bonifacio, A., Akiskal, K.K., Akiskal, H.S., 2007. Validation of the TEMPS-A Buenos Aires: Spanish psychometric validation of affective temperaments in a population study of Argentina. J. Affect. Disord. 100, 23–29. Yoon, J.H., Kim, J.H., Choi, S.S., Lyu, M.K., Kwon, J.H., Jang, Y.I., Park, G.T., 2012. Homicide and bipolar I disorder: a 22-year study. Forensic Sci. Int. 217, 113–118. Zimmermann, P., Brückl, T., Nocon, A., Pfister, H., Lieb, R., Wittchen, H.U., Holsboer, F., Angst, J., 2009. Heterogeneity of DSM-IV major depressive disorder has a consequence of sub-threshold bipolarity. Arch. Gen. Psychiatry 66, 1341–1352.
