Affective Temperaments in Bipolar I Patients in Tunisia (A Study Using the Tunisian Validated Version of the TEMPS-A)

Research Article

J Schizophr Res. 2017; 4(1): 1029.

Affective Temperaments in Bipolar I Patients in Tunisia (A Study Using the Tunisian Validated Version of the TEMPS-A)

Jomli R*, Abdelghaffar W, Ouali U, Zgueb Y, Lassoued W and Nacef F

Service de Psychiatrie A, Hôpital Razi, Tunisia

*Corresponding author: Jomli R, Service de Psychiatrie A, Hôpital Razi, Manouba, 2010 Tunis, Tunisia

Received: August 27, 2016; Accepted: March 13, 2017; Published: March 21, 2017


Background: The study of affective temperaments is of interest for psychiatrists as they have an impact on the clinical expression and the prognosis of bipolar disorder.

Method: This is a cross-sectional, descriptive and analytical study on 100 patients with Bipolar Disorder type I in clinical remission, that were recruited from 1 february 2013 to 30 June 2013 at the Department of Psychiatry A of Razi Hospital. We used the Tunisian validated version of the TEMPS-A for assessment of affective temperaments.

Results: The sex-ratio was 1,3. Average age of patients was 41 years. Highest average scores were obtained for hyperthymic temperament (12,97) and for cyclothymic temperament (10,03). Age was positively correlated with hyperthymic temperament (r=0,197; p=0,050). Average score of anxious temperament was inversely correlated with psychotic features during first affective episode. (p=0,015). A positive correlation was found between a history of mixed episodes and the average score of depressive temperament (p=0,043. The average score of cyclothymic temperament was positively correlated with the number of mixed episodes (r=0,231; p=0,021). The duration of the disorder was positively correlated with hyperthymic temperament (r=0,263; p= 0,008) and negatively correlated with anxious temperament (r=-0,201; p=0,045). The choice of therapeutic strategies was little influenced by affective temperaments.

Limitations: The cross-sectional design of the study, the small sample size, our sample consisted of former inpatients exclusively, concurrent pscychopharmacological treatment which can be a confounding factor.

Conclusion: Assessment of affective temperaments should be taken into consideration in the diagnosis, prognosis and therapeutic decision making of bipolar I patients.

Keywords: Affective temperaments; Bipolar disorder; TEMPS-A


TEMPS-A: Temperament Evaluation of Memphis, Pisa, Paris and San Diego-autoquestionnaire version; TEMPS-I: Temperament schedule of Memphis, Pisa, Paris and San Diego, Interview version; DSM -IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision; SPSS: Statistical Package for Social Sciences


The temperament refers to individual characteristics, supposed to be of biological or genetic origin. It determines affective, relational, attentional and motor reactions to different situations and plays an important role in social functioning. The concept of affective temperaments has been studied in order to comprehend human behavior and psychopathological risk factors for different mental disorders, in particular affective disorders [1,2]. Affective temperaments can be defined as a temporally stable dimension which consists of constitutive, heritable and independent traits which largely determine the bipolar phenotype [1,3,4]. Indeed, temperaments can be understood as behavior al endophenotypes of mood disorders, or genetic predispositions to certain mood states [5]. The first types of temperaments individualized by Akiskal in 1979 were: depressive, hyperthymic, and cyclothymic temperament, followed by the irritable temperament in 1987 and the anxious temperament in 1998 [6,7]. The five factor structure of the model was confirmed when the short version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A) was validated. Several studies explored the role of affective temperaments in the onset and the clinical features of mood episodes, the prognosis of mood disorders and their comorbidities [1,8-11]. Future studies need to confirm statistically the factorial distribution of temperamental traits, and to analyse the relation ships between temperamental traits, mood states and mood disorder [12]. However, in clinical practice, the evaluation of the underlying temperament receives little attention compared to the mood episodes. So far, very few Tunisian studies have investigated this subject.

The objectives of our study were:

• to evaluate affective temperaments in patients bipolar disorder type I in remission, and

• to explore the relationship between affective temperaments and clinical as well as prognostic variables of the disorder.


This is a cross-sectional and analytical study that was conducted at the out patients clinic of Psychiatry «A» department of «Razi» Hospital from 1 February to 30 June 2013.

Participants’ inclusion criteria were:

- follow up for Bipolar Disorder type I according to DSM-IV-R.

- age = 18 years

- illness duration =1 year

- remission from last affective episode = 8weeks

- informed consent of patient to participate in the study

Participants’ exclusion criteria were:

- mental retardation

- Cognitive impairment (dementia)

- illness duration < 1 years

- substance induced bipolar disorder or affective disorder due to a general medical condition.

Description of the study and assessment instruments: Data was collected from the patients’ medical files, and completed by face to face interviews, with the help of a pre-established questionnaire containing socio-demographic and clinical variables and the TEMPS-A questionnaire in its Tunisian-arabic validated version. All interviews were conducted by the person (WL), one of the authors of the study and Psychiatry resident. Interviews took place at the Department of Psychiatry «A» of Razi hospital, and had an approximate duration of 30 to 60 minutes. Affective temperaments were assessed with the help of the The TEMPS-A questionnaire. It was developed as a semi-structured interview (TEMPS I) at the university of Tennessee, Memphis, by Akiskal. It was initially validate din 1998 in a sample of students. On the basis of TEMPS I, Akiskal elaborated 2005 in San Diego an auto-questionnaire, the TEMPS-A. This version of the questionnaire was validated in numeruous countries and languages. In Tunisia, the TEMPS-A in its Tunisian-Arabic version was validated in 2010, as part of a doctoral thesis. This scale is composed of 110 items for females and of 109 items for males. It describes the five dimensions: depressive temperament (items 1-21), cyclothymic temperament (items 22-42), hyperthymic temperament (items 43-63), irritable temperament (items 64-84), and anxious temperament (items 85-110). The factorial score of each of the five dimensions is obtained by scoring each positive response to an item with one point. The total score for each dimension is obtained by adding up all positive responses. Therapeutic compliance during the past two years was qualified as «good» in case of complete adherence to treatment, as «medium» if patient stopped treatment not more than once in a year, and as «low» if treatment was stopped two times or more per year.

Data analysis

Data analysis was performed using the software package SPSS in its 18th version. The impact of affective temperaments on sociodemographic and clinical variables was analysed by multivariate tests, ANOVA tests, and by calculating the Pearson correlation coefficient.


Socio-demographic and clinical description of the sample: Sex ratio was 1,3 and average age of participants was 41 years. Sociodemographic data is presented in (Table 1). A family history of affective disorders was present in 52 patients (52%), of whom 63,5% (n=33) reported a family history of bipolar disorder. Somatic comorbidity was dominated by endocrine diseases (58,8%, n=10), and psychiatric co-morbidity was found in two patients who had obsessive compulsive disorder. Suicide attempts were comitted in most cases (82,6% n=19) during an affective episode (Table 1). Substance use, abuse or dependence as found in 44% of study participants (n=44). Tobacco was the most consumed substance (41%, n=41) Table1. The principal clinical data were presented in (Table 1). The first thymic episode was principally manic and it was hard with the presence of psychotic characteristics for 60% of the cases (Table 1). The average duration of the hospitalisation for the first episode was 2,68±1,3 weeks. Among the study treated patients, 2% (n=2) had rapid cycles according to the criteria of DSM-IV-R. A seasonal feature of the bipolar disease was found in 26% (n=26) of the patients. The quality of free intervals was good in the majority of cases (96%, n=96). Antecedents of mixed episodes were found for 35% (n=35) of the patients. The majority of thymic episodes was of manic nature (Table 2). The average duration of the treatment by the last prescribed moodstabiliser was of 9,25±6,8 years. The majority of patients were under the effect of Valproic Acid (75%, n=75), 17 patients were under carbamazepine, 1 patient was under lithium, 1 was under lamotrigine, the remaining patients were under the combination of moodstabilisers (4 under lithium+valproate and 1 under lithium+carbamazepine and 1 under valproate+ carbamazepine). Half of patients were under classical Neuroleptics (50%), 13 were under atypical antipsychotics (13%) and more than half (58%, n=58) were under benzodiazepine at the moment of the study. The compliance of the treatment was good for 38% (n=38) of the cases, average for 37% (n=37) of the cases and bad for 25% (n=25) of the cases. The average scores of cyclothymic temperaments(10,03±5,7) and hyperthymic ones (12,97±4,5) were the highest (Table 3).