Research reportThe influence of affective temperaments and psychopathological traits on the definition of bipolar disorder subtypes: A study on Bipolar I Italian National sample
Introduction
Affective temperaments are supposed to represent behavioral endophenotypes genetically related to mood disorders (Akiskal et al., 2006b, Evans et al., 2005, Evans et al., 2008, Gonda et al., 2009, Gonda et al., 2006, Rihmer et al., 2007) and possibly increasing the predisposition for developing affective states (Evans et al., 2005, Rottig et al., 2007). Yet, the concept of fundamental, constitutional, biologically determined, temperamental traits as background of mood states and major affective illness, is not a novel acquisition. In fact, Kraepelin [1921] already observed that the cyclothymic, irritable, anxious, depressive “fundamental states” preceded the onset of several manic-depressive episodes, and persisted also during the “lucid” intervals; those observations led him to consider affective temperaments as attenuate expressions of manic-depressive illness as well the background for overt clinical forms (Kraepelin, 1921).
Affective temperament and psychopathological traits are also supposed to have an impact on the clinical manifestation and on the course of Bipolar Disorder (BD) (Akiskal, 2000, Hantouche et al., 1998). However their predictive value on outcome still requires further research. This is particularly true for putative temperamental (e.g. cyclothymia and hyperthymia) and psychopathological traits (e.g. separation anxiety and interpersonal sensitivity), which might play a predisposing or pathoplastic role in the antidepressant-induced (hypo)manic vulnerability (Akiskal et al., 2003b) and/or in several co-morbid syndromes—for review see (Perugi and Akiskal, 2002).
Most of the available literature on the pathoplastic role of temperament is focused on Bipolar II (Akiskal et al., 2003a, Benazzi, 2007, Cassano et al., 1992) or Unipolar samples (Maina et al., 2009). For example, arising from a cyclothymic temperament, the bipolar II patient could pursue an unstable course (Akiskal et al., 2003a), present multiple co-morbidities with anxiety, eating and alcohol/substance use disorders (Perugi et al., 2006), an increased risk for suicidal behavior (Kochman et al., 2005) and could be more likely to be misdiagnosed as an axis II cluster B (Hantouche et al., 2003). In the same line, unipolar patients with cyclothymia or hyperthymia are reported to have earlier age at onset, higher rates of cluster B personality disorder and first-degree family history for BD in comparison with unipolar patients without such a temperamental profile (Maina et al., 2009). The only reports in Bipolar I patients focused on the relationship between temperament and mixed states (Akiskal et al., 1998a, Rottig et al., 2007), supporting the hypothesis that mixed episodes are more frequent in subjects with inverse temperaments (Akiskal and Benazzi, 2003).
Separation anxiety (SA) is included in DSM-IV among childhood and adolescence disorders and it has been typically described in juvenile populations and/or as a childhood antecedent of panic/agoraphobic spectrum disorders (APA, 1994). An adult form of excessive and often disabling distress in the face of actual or perceived separation from major attachment figures has been recently described (Silove et al., 2007). Epidemiological (Bruckl et al., 2007, Shear et al., 2006) and clinical (Costa et al., 2009) data supported the hypothesis that early SA tends to persist in adulthood and operates as a general vulnerability factor for adult anxiety or mood disorders. In particular, juvenile and adult SA have been associated with the development of bipolar spectrum disorders (Pini et al., 2005, Toni et al., 2008).
Interpersonal sensitivity (IPS) is a construct referring to an individual's hypersensitivity to perceived self-deficiencies in relation to others. Partially related to weak self-esteem, it embraces sensitivity to rejection and criticism on the part of others (Davidson et al., 1989). IPS can be defined and rated with good reliability (Stafford, 2007) and has good construct validity, acceptable factorial invariance and differential sensitivity to the effect of treatment (Davidson et al., 1989). A long-standing pattern of rejection sensitivity has been included in DSM-IV as a diagnostic criterion for Atypical Depression. The inclusion of a stable psychopathological trait for axis I syndromes has no precedent and automatically increases the severity and continuity of the syndrome. Increasing evidence for an overlap between traits and states symptomatology in mood disorders suggests that systematic consideration of combined features may be worthwhile (Clayton et al., 1994). In a study conducted by our group in a large sample of patients with atypical depression, mood instability of cyclothymic type resulted strongly related to IPS and to mood reactivity, suggesting the existence of a common background (Perugi et al., 2003). In BD II patients with atypical depression, IPS and mood reactivity seem to be two strictly related characteristics, representing two different features, cognitive and affective, of the same psycho(patho)logical dimension (Perugi et al., 2003).
The aim of this study is to explore, in a national sample of BD I patients, the influence of affective temperaments and psychopathological traits such as separation anxiety and interpersonal sensitivity, prospectively evaluated during the euthymic phase, on the clinical features and the course of BD.
Section snippets
Design of the study
At the end of 2002, an advisory board composed by international experts on mood disorders projected a multi-centric, naturalistic study. The study would have held in Italy and focus on the clinical antecedents, psychiatric co-morbidity, and course characteristics of a national sample of acute manic or depressive Bipolar I patients. The centres involved in the study, after the approval of the local ethical committees, were 10: Rome, San Benedetto del Tronto, Barcellona Pozzo di Gotto, Brescia,
Results
Patients that at the last observation were in remission (n = 89, 84%) did not differ from the rest of the sample (n = 17, 16%) concerning demographic features and clinical features. The only exception was mean age that was higher in remitting patients than in the rest of the sample (43.09 ± 13.61 vs. 36.71 ± 11.04, p = 0.028). The temperament profile and the mean score of separation anxiety and interpersonal sensitivity scales were similar in the two groups.
According to the Pearson's correlations among
Discussion
Before discussing the substantive findings of our study, we wish to point out a few methodological issues which must be taken into account in interpreting our results. Because this study was conducted in routine clinical services, clinicians who evaluated these patients could not be held entirely blind to the various measures administered. On the other hand, investigators were psychiatrists who were sophisticated in clinical evaluation—rather than mere raters of psychopathology—thereby ensuring
Role of funding source
The study was supported by Novartis. Novartis did not participate in the protocol drafting, nor in the data collection process or in any other phase of the data analysis and the editing of the paper.
Conflict of interest
The authors have no conflict of interest, but the role of the funding source, to state for the present manuscript.
Acknowledgement
The authors acknowledge Novartis for the financial support for this study.
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