TEMPERAMENTS, MELANCHOLY AND MANIA

Maria Luisa Figueira, Mario Di Fiorino, Angelo G. I. Maremmani

TEMPERAMENTS, MELANCHOLY AND MANIA

1. Introduction

The roots of the current classification of affective disorders can be traced back to Ancient Greek medicine. The term itself of melancholy had origin from the theory of humours and during many centuries melancholy has been employed in order to designate different mental disorders, also if the established clinical employ defines the decrease (deflection) of mood. Only during the eighteenth century the term depression begins to be used, for the first time by Samuel Johnson (Jonhson, 1969). The history of the melancholia is the history of the debate among the different views of mental illness. The reaction to biological reductivism is represented by the warning of the theologian and philosopher Romano Guardini: there is the need of a not reductivistic attitude when we cope the world of melancholic patient, to the reflection on our inadequacy, on our misdeeds and generally on the deeper questions of man (Guardini, 1928). We can only partly agree with this warning, as the classical psychiatry, without any doubt on the biological nature of depression, has taught us that in melancholic delusions (hypochondriac, of guilt and ruin) we can notice the primordial anxieties of man about the health of body, the salvation of the soul and the needs of life, according to the expressions of Kurt Schneider (Weitbrecht, 1963). Only remembering this traditional biological nature we can convince the depressed patient to follow treatment, instead of leaving him in a impotent contemplation, alone with a fatalistic attitude and with the feelings of guilty.

In the modern concepts of temperaments, endogenous and melancholy we can find accents of Ancient Greek medicine (Lanczik and Beckmann, 1991). While in its clinical guise melancholia leads to stagnation, rigidity and insistent hopelessness, popularly with the term melancholicus we refer to a very different meaning: a person with tendencies to reflection, insight and self-knowledge (Spitz, 2001).

• The theory of humours

The term melancholia had origin from the theory of humours (humoralism). Melancholy is the Latin transliteration of μελαγχολία, which derives from μέλαινα χολη (in Latin atra bilis), black bile. You meet the term first in the oldest part of Corpus Hippocraticum (V century B.D.), where it indicates an illness caused by a quality of bile (χολώδης). In the last Hippocratic writers the corresponding type is indicated with higher precision as μελαγχολικός and the same adjective is used with other similar expressions (άθυμος, δυσφορία) for describing a mental or humoral state of depression and sadness (τά περί τήν γνώμην μελαγχολικά) (Muller, 1980).

… omissis..

• The relationship between personality/temperament and illness

The different relationships and interactions between personality/temperament and illness in affective disorders have been classified according to the following models (Akiskal et al., 1983; Ehrt et al., 2003; Klerman, 1973):

• Personality predisposes a person to develop an affective disorder. Already Tellenbach had underscored these aspects in depression; Beck has radicalized this position, isolating the cognitive aspects from the mood.
• Temperament (which has a more constitutional, biological basis than personality) represents the core characteristic of the illness (model of the dilution of full-blown affective disorders). Kretschmer has made clear the Kraepelinian view. Substantially, it is the point of view of Leonhard (Leonhard, 1957) and Akiskal (Akiskal et al., 1979).
• The premorbid personality can modify the clinical presentation of affective disorders, the interpersonal relationship and the compliance to treatment (Klerman, 1973).
• Depression induces changes in personality: depressive defect (Helmchen and Mueller-Oerlinghausen, 1975), residual syndromes (Glatzel, 1973); Janzarik (Janzarik, 1968), residual states (Maneros et al., 1990).

Olothymic conception could represent a very simplified conceptualization of 2^nd type; it puts in brackets the temperament; deflection and expansion of mood modify convictions until delusion. Emphasis of post-depressive remainder (the conceptualization of 4th type) is in opposition to the Kraepelinian paradigm, which was founded on the criterion of the course in order to distinguish maniac-depressive illness from schizophrenia: in the latter we find the defect, whereas in maniac-depressive illness there are interval phases between the episodes of opposite polarity.

In this sub-categorization, founded on the interactions between temperament and illness, we can introduce also the role carried out by the life events:

1. An accentuation of traits of personality without an influx of the events according to the concept of development of Karl Jaspers (1959).
2. Key Experience (or Event), when a precipitating event (Key Experience, in German Schlüsserlebnis), occurred in a specific (like a key in a lock) personality at a particular time of person’s life.
3. The events are not always casual, but they are looked for by the typus: “It is the man who looks for the circumstances that disconcert him” (Ortega Y Gasset, 1930). These dynamics are illustrated in the constellations of Including and Remaining of the Typus melancholicus by Tellenbach, where there is a “sliding” into the illness.

Lara and colleagues build a spectrum model that integrates the advantages of Cloninger’s and Akiskal’s approaches to personality and temperament, underlining their relationship with affective disorders (Lara et al., 2006). They specifically propose that “fear” and “anger” traits – used in a broader connotation than in the conventional literature – provide an optimum basis for understanding how the spectra of Anxiety, Depressive, Bipolar, Attention Deficit/Hyperactivity, Alcohol, Substance Use and the Impulse-Control, as well as Cluster B and C Personality Disorders arise and relate to one another.

1. Affective Temperament according to Akiskal and Mallya conceptualization. the modern classification

According to Akiskal and Mallya conceptualization, based on Kraepelin theory and clinical observations, four fundamental affective temperaments do exist: the depressive temperament is characterized by stably depressed mood, introversion, low energy level and hypersomnia; hyperthymic temperament is characterized by extroversion, high energy level, emotional intensity and little need for sleep; the cyclothymic temperament represents a central dimension including rapid fluctuations of mood and emotional instability; the irritable temperament, less consistent than the others, includes litigiousness, aggressiveness and difficulties in interpersonal relationships. Lately it has been elaborated a putative phobic-anxious temperament consisting of increased sympathetic activity, fear of illness, hypersensitivity to separation, difficulty to leave familiar surroundings, marked need for reassurance and oversensitivity to drugs and substances (Akiskal and Akiskal, 1992; Akiskal et al., 1998b; Cassano et al., 1992; Corretti and Di Fiorino, 2005; Del Debbio et al., 2012; Di Fiorino et al., 2010; Perugi et al., 1998; Perugi et al., 2003; Phillips et al., 1990; Placidi et al., 1998b; Soldatich et al., 2005).

Nowadays, it is widely debated whether affective temperaments belong to the domain of pathology or to that of normality. Within the general framework of evolutionary biology it has been suggested that affective disease, including mania and associated psychotic states, exists because it serves, in a polygenic model, as the genetic reservoir for adaptive temperaments. If we conceptualize affective disorders as extremes in an oligogenic model of inheritance, adaptive temperaments represent the dilute phenotypes of their constituent traits. Depressive traits would provide sensitivity to the suffering of other members of the species, overlapping with those of the generalized anxious temperament. Cyclothymia may have evolved, thanks to the role played by creativity in sexual seduction, as a mechanism in reproductive success. Hyperthymic traits would lend distinct advantages in leadership, exploration, territoriality and mating. According to this comprehensive model, creative and eminent individuals might occupy a somewhat unstable terrain between temperament and affective disease (Akiskal and Akiskal, 2007; Akiskal and Akiskal, 2005).

The whole question of the nature of affective temperaments is still an open issue. The concept of temperament derives from the clinical tradition, (Akiskal, 1994; Akiskal, 2000; Akiskal and Akiskal, 1992) and in Diagnostic Statistic Manual (DSM), affective temperaments are classified among mood disorders, as cyclothymic and dysthymic disorders (A.P.A., 2000, 2013). As a matter of fact the validation process of Akiskal and Mallya (Akiskal and Mallya, 1987) criteria for the diagnosis of affective temperaments, both in their auto-questionnaire and interview version, has confirmed that affective temperaments are a widespread dimension in the general population with significant sex, age and latitude related differences (Akiskal et al., 1998b; Albanesi de Nasetta and Vazquez, 2007; Bloink et al., 2005; Borkowska et al., 2010; Figueira et al., 2008; Karam et al., 2005; Placidi et al., 1998a; Placidi et al., 1998b; Pompili et al., 2008; Preti et al., 2010; Rozsa et al., 2006).

Numerous studies exploring the diffusion of affective temperaments among general population and their involvement both in pathological conditions (somatic and psychiatric) and in human activities (professions and other occupations) point to elucidate, according to an integrated model, the position of affective temperaments within the continuum between normality and pathology.

•  Psychometrics of affective temperaments
  •    Development of TEMPS-I, TEMPS-A, TEMPS-A[P]

The Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS), both in interview and auto-questionnaire versions, is based on Akiskal and Mallya criteria for affective temperaments, validated in a Italian population of 1010 students aged from 14 to 26 years. Item wording and selection have been performed through an iterative process that incorporated feedback from clinicians and researchers (Akiskal, 1994; Akiskal, 2000; Akiskal and Akiskal, 1992). The interview version of TEMPS (TEMPS-I) is a 20-minutes interview usually administered by two psychiatrists. It has been designed to quantify temperament in psychiatric patients and healthy subjects, and includes sections on emotional reactivity, and on cognitive, psychomotor, circadian and social-behavioural traits (Akiskal and Mallya, 1987; Akiskal et al., 1998b; Placidi et al., 1998b).

The auto-questionnaire version of TEMPS (TEMPS-A) is a self-reporting, yes-or-no type questionnaire formulated on the basis of the same diagnostic criteria for affective temperaments. The first version contained 84 items, assessing dysthymic, cyclothymic, hyperthymic and irritable temperaments. Later, clinical and theoretical considerations have led to the addition of 26 new items describing the anxious temperament, thus resulting in the full, 110-item-long version of the TEMPS-A (Akiskal et al., 2005a; Perugi et al., 1998).

 Subsequently TEMPS-A has been translated and validated in several languages, both in short and extended version. Among the Italian versions of TEMPS-A, a particular case is represented by TEMPS-A[P], a 61-item, made in Pisa auto-questionnaire, directly derived from the Italian version of TEMPS-I and including the four classical subscales for dysthymic, cyclothymic, hyperthymic and irritable temperaments (Maremmani et al., 2011a; Maremmani et al., 2010b; Rovai et al., 2012a; Rovai et al., 2012c).

•             Cloninger’s Tri-dimensional Personality Questionnaire (TPQ) and personality disorders

In the Italian population of 1010 student, which participated to the validation of Akiskal and Mallya criteria for affective temperaments, TEMPS-I has been compared with Cloninger’s revised “Tri-dimensional Personality Questionnaire” (TPQ) deriving from the experimental psychology tradition. As expected high harm avoidance and depressive temperament were correlated. High novelty seeking was related both to the hyperthymic and to the cyclothymic temperament. Cyclothymic traits were related to both harm avoidance and novelty seeking dimensions, in line with the Kretschmer’s hypothesis of a central cycloid temperament. In a more theoretical vein, hyperthymic-novelty seeker should be overrepresented among those with high achievement; while a moody, restless disposition (a cyclothymic-harm avoidant type) should be liable to negative affective arousal. These considerations could shed some light on the origin of socially adaptive behaviour (‘sunny’ or sanguine types) on the one hand, and borderline conditions typical of anxious-hostile bipolarity (‘dark’ types) on the other (Maremmani et al., 2005a).

There are no many studies looking at the relationship between affective temperament and personality disorders. A previous work about the linkage between the two was performed on a clinical sample of bipolar disorder patients. In this sample cyclothymic, irritable, anxious and depressive temperament were associated with each other, while hyperthymic temperament was independent. When correlated with personality disorder, cluster A personality disorder didn’t show any association with depressive, cyclothymic and irritable temperament. Cluster B personality disorder were associated with higher scores in depressive, cyclothymic and irritable temperament and cluster C personality disorder shown a positive association with higher scores in cyclothymic and irritable temperament (Di Fiorino et al., 2008; Martinucci et al., 2011; Massei et al., 2009).

•             Multiphasic Personality Inventory (MMPI)

In a sample of 693 candidates applying to become cadets in the Italian Air Force TEMPS-A[P] has been correlated with the MMPI validity and clinical scales after a stressful challenge represented by the academy entrance trial. MMPI is a self report questionnaire designed to identify personality structure and psychopathology in psychiatric patients and healthy volunteers. As regards MMPI validity scales, TEMPS-A[P] depressive candidates tended to report their symptoms sincerely, hyperthymic candidates tended to give false answers to be seen in a good light. Cyclothymic and irritable candidates tended to exaggerate symptoms. As regards the MMPI clinical scales, a low linkage between affective temperaments and abnormal personality traits has been found. From a personological point of view temperaments have proved to belong to the realm of normality rather than to the realm of pathology, in line with their putative adaptive role (Maremmani et al., 2010a).

•             Occupational Personality Questionnaire (OPQ32)

In order to understand the extent to which affective temperaments are adaptive, it would be useful to know if they influence the work related abilities of subjects. In a sample of 921 candidates applying to become cadets in the Italian Navy, TEMPS-A[P] has been correlated with Occupational Personality Questionnaire, ipsative version (OPQ32i), during a stressful challenge represented by the entrance examination. OPQ32 is a self-report personality questionnaire designed to give information on an individual’s preferred behaviour, as assessed in terms of a number of work-related characteristics. Depressive temperament was reported to imply a low level of ability to relate to others; hyperthymic temperament was characterized by high levels of feelings and emotions, and by the capability to relate to people; cyclothymic temperament was distinguished by creativity and a low level of relationships with others; irritable temperament showed to overlap with cyclothymic temperament, the main difference being the higher level of energy and the lower level of empathy of irritable subjects. The four affective temperaments proved to significantly differ in the work capacity features measured by OPQ32 factors. These observed correlations further support the hypothesis that temperaments belong to the realm of normality rather than that of pathology (Rovai et al., 2012b).

1. Affective Temperaments and psychiatric pathologies

In literature affective temperaments have been reported to correlate with a wide series of psychiatric disorders, including not only affective disorders but also substance use disorders.

•    Psychiatric pathology

Some authors affirms that temperamental dysregulation may represent the phenotypic expression of the underlying bipolar genotype (Akiskal, 1983; Akiskal, 1989; Akiskal et al., 1989; Akiskal and Mallya, 1987; Alexinschi et al., 2012; Cassano et al., 1989), and on the basis of this connection have explored the role of affective temperaments in pathological conditions such as mood disorders and substance use disorders.

With reference to mood disorders, it has been shown that affective temperaments influence the clinical features of bipolar disorders in terms of both clinical and course characteristics. For example depressions arising from a cyclothymic temperament, likely to be misdiagnosed as personality disorders, presented, in 194 patients of a French national multi-site study, high familial load for mood disorders, validating its putative bipolar nature. These patients, characterized as the “darker” expression of the more prototypical “sunny” type-II bipolar phenotype, seem to represent a more “unstable” variant of bipolar disorder (Akiskal et al., 2003). Among 106 bipolar type-I patients of a multi-centric Italian study, dominant cyclothymic and hyperthymic subjects reported important differences in terms of gender distribution, family history, number and polarity of previous episodes, hospitalizations, suicidality, rates of co-morbid anxiety and personality disorders. These observations are consistent with the hypothesis that affective temperaments, and in particular cyclothymia, could be utilized as quantitative, intermediate phenotypes in order to identify bipolar disorders susceptibility genes (Perugi et al., 2010). Other evidences have supported the familial, possibly genetic, role of the hyperthymic temperament in the genesis of bipolar I disorder and pure mania, suggesting the higher specificity of the cyclothymic temperament to the bipolar II subtype and mixed states (Akiskal et al., 2003; Akiskal et al., 1998a; Kesebir et al., 2005; Perugi et al., 2010; Rottig et al., 2007). Affective temperaments also showed to influence the pathogenesis of mixed states like mixed mania, as reported in a sample of 104 manic patients during the acute hospital phase. The reversal from a temperament to an episode of “opposite” polarity seems to represent a fundamental aspect of the dysregulation that characterizes bipolar disorder. Both men and women with hyperthymic temperament, appeared to be protected against depressive symptom formation during a manic episode, which, accordingly, was relatively “pure”. Pure mania would be overrepresented in men because they have higher rates on the hyperthymic temperament, while picture of mixed mania would be more typical of women, consistently with their well-known tendency for depression. All these evidences support the general idea that “mixity” should be conceptualized as intrusion of mania into its “opposite” temperament, especially in females (Akiskal et al., 1998a; Rottig et al., 2007). More recently affective temperaments have been explored in a sample of 153 maniac inpatients, divided into five groups according to the symptomatological subtype of mania (Depressive, Irritable-Agitated, Euphoric-Grandiose, Accelerated-Sleepless, Paranoid-Anxious). The patients belonging to ‘Euphoric-Grandiose’, ‘Paranoid-Anxious’ and ‘Accelerated-Sleepless’ subtypes were those most likely to present a hyperthymic temperament, while the ‘Depressive’ dominant group had the highest rate of depressive temperament. The ‘Irritable-Agitated’ group was high for both temperaments. A hyperthymic temperament seemed to underlie the most extreme manic excitement with euphoric-accelerated-paranoid phenomenology. By contrast, the depressive temperament seemed to mute the expression of mania into a depressive-manic phenomenology (Perugi et al., 2001). Finally affective temperaments have been also reported to modulate gender related differences among bipolar patients. In a sample of 538 subjects with primary mood disorders, females, with respect to males, presented lower number of hypomanic, and higher number of depressive episodes, with higher rate of comorbid anxiety disorders and somatisation. Moreover they were more likely to exaggerate symptoms and to undergo hospitalization. These gender differences could in part be explained by the higher prevalence of the depressive temperament in women, and of the hyperthymic temperament in men (Perugi et al., 1990).

•    Substance abuse disorders

Given the generally accepted link between substance use disorders and bipolarity (Maremmani et al., 2000a; Maremmani et al., 2000b; Maremmani et al., 1994; Maremmani et al., 2012; Maremmani et al., 2005b; Maremmani et al., 2004; Maremmani et al., 2008; Maremmani et al., 2006), affective temperaments have been studied in heroin addicts, alcoholics, and cocaine abusers.

With regard to heroin addiction, which represents the paradigm of addictive disorders, the temperamental traits of 59 consecutive stabilized methadone treated heroin addicts have been compared with those of 58 healthy volunteers sharing similar social and regional demographics. Cyclothymic, and to a lesser extent irritable traits (the “dark side”), were reported to represent the temperamental profile of heroin addicts (Maremmani et al., 2009). With regard to alcohol abuse, ninety-four consecutive responders to treatment alcoholics have been compared, regarding affective temperaments, with 50 healthy volunteers displaying the same social characteristics and belonging to the same environment. Alcoholics were distinguished from controls in terms of cyclothymic traits, with a depressive component. These characteristics tend to cohere with previous conceptualizations hypothesizing “sensation-seeking” and “novelty-seeking” dimensions as the main personality characteristics of addiction (Pacini et al., 2009). In order to understand if the prevalence of cyclothymic traits among heroin addicts and alcoholics was due to the co-occurrence of a full blown bipolar disorder, in the two previously mentioned papers authors have compared the temperamental traits of dual diagnosis patients with those of patients without a dual diagnosis. The cyclothymic disposition was not able to differentiate these two groups of patients, prompting the idea that the importance of cyclothymia in addictive disorders is unrelated to the presence of dual diagnosis (Maremmani et al., 2009; Pacini et al., 2009).

Temperaments have been evaluated also in the field of stimulant abuse, with the aim to delineate the nature of a hypothesized stimulant bipolar spectrum. Among stimulant abusers, cyclothymic and hyperthymic traits have proven to preceded by years the use of stimulants, which seemed to serve the purpose of maintaining the subthreshold rewarding mood elation. It seems to be corroborated a bipolar-stimulant spectrum where subthreshold bipolar traits are complicated by stimulant abuse, eventually leading to new pathological features in both disorders (Camacho and Akiskal, 2005).

1. Affective Temperaments and “goodness to fit”

In order to understand the extent to which affective temperaments are adaptive, we must ask ourselves how they influence the quality of life. A multi-centric Argentine study has assessed, among clinically unaffected relatives of bipolar patients, the prevalence of affective temperaments and their impact on the quality of life. Bipolar patients’ relatives, compared to controls, showed higher scores on all TEMPS-A subscales, except for the hyperthymic one. Only in the case of hyperthymic subjects, quality of life of cases was equal to that of controls, further qualifying hyperthymia as the most adaptive temperamental subtype (Vazquez et al., 2008).

1. Affective Temperaments and professional choice

Affective temperaments have been explored also in the wide field of human activities, with the purpose of delineating the temperamental profile of specific professional fields.

•    Professional choice in outpatients

Temperamental traits have been assessed in a sample of 263 psychiatric outpatients involved in several professional fields. Dysthymic and obsessional attributes were notable in lawyers and physicians. Cyclothymia seemed to be the dominant affective temperament of artists and architects, while hyperthymic temperament appeared a central dimension in managers, self-made industrialists, and journalists. The role of cyclothymic and hyperthymic temperaments turned out to be moderated by obsessional traits. In particular, artists’ creativity was “liberated” by low levels of obsessive traits, whereas among architects, relatively high levels of obsessive traits contributed to the execution of their work. Journalists, as a group, showed to possess the broadest representation of affective temperaments (Akiskal et al., 2005b).

•    Professional choice in student populations

In order to assess the role of affective temperaments in determining personal choices and aspirations, it has been described the temperamental profile of 1386 students aspiring to enter different professional fields. Future physicians did not show a predominant temperament, future lawyers and artists presented predominantly a cyclothymic or irritable temperament, future engineers presented a hyperthymic temperament and future psychologists and nurses showed predominantly depressive and anxious temperaments (Figueira et al., 2010).

•    Professional choice in applicants

Recently a temperamental trait of 1548 applicants to become a cadet officer was studied in the Italian air force. Extremely high scores on the hyperthymic scale combined with extremely low ones in the cyclothymic scale seemed to correspond to the specific temperament profile and to the highest likelihood of success in young applicants. Those who took the entrance examination proved to be more hyperthymic than their peers, and the specificity of this correlation was confirmed by the fact that applicants who made a second attempt to pass the entrance examination after an initial failure were more hyperthymic than first-time applicants. Also the success in specific psychological admission tests was related to the same temperamental profiles, since those who proved to be psychologically fit were more hyperthymic (Maremmani et al., 2010b). In a study carried out on the same military division it was inquired into the question whether gender differences in temperament have continued unchanged in a field, such as the military career, that has been historically characterized by a male identity. In general population, males and females have shown different temperamental profiles. As a matter of fact, over the past fifty years in the Western world the professions and activities that were once practiced only by males, are now available to females, too. Among our aspiring cadets, both males and females showed high scores on the hyperthymic scale (generally, a typical male temperament) and very low ones on the cyclothymic scale (generally, a typical female temperament). Low scores were also observed on the depressive and the irritable scales. These observations support the idea that different gender-related temperaments are functional to differences in the roles played by males and females during the biological and social evolutionary process (Maremmani et al., 2010b). In another study this investigation was extended to another military service such as the Italian Navy. It was compared temperaments between those who had applied to become a cadet officer in the Italian Air Force or in the Italian Navy, with special reference to gender differences and the ability of the two types of applicants to pass the psychiatric examination for admission. Hyperthymic traits were well represented in both these armed services. Navy applicants differed from air-force applicants in obtaining higher depressive, cyclothymic and irritable scores. Navy applicants who passed the psychiatric entrance examination showed the same incidence of hyperthymic temperament as their Air Force counterparts, but higher depressive, cyclothymic and irritable scores (Rovai et al., 2012b). Hyperthymic temperament turns to represent the temperamental profile of those who aim to become a cadet officer in two Italian army divisions.

To enter a particular professional field, personal aspirations and attitudes are not the only features to be required, and other professional skills might be necessary. To date there is a unjustified lack of data on the correlation between temperamental profile and ability to pass examination tests. In order to fill this gap, correlations were tested between affective temperaments and step-by-step results during the entrance examination of 921 applicants to be a cadet of Italian Navy. Hyperthymic temperamental traits resulted to be important not only in the professional choice, but also in passing the entrance examinations. Nevertheless, affective temperaments (high hyperthymic and low cyclothymic, depressive, irritable traits) successfully predicted only psychiatric examination and to a lesser extent the medical and attitudinal one. Getting high school graduation and passing mathematical exam was independent from temperamental traits, and seemed to be influenced by personal skills not strictly related to temperaments (Rovai et al., 2013). These data corroborate the hypothesis that hyperthymic traits bring distinct advantages in a professional field, such as a military career, which is closely related to leadership.