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

  

    
Affective temperament 
    
Depressive 
    
cyclothymic 
    
Hyperthymic 
    
Irritable 
  
  

    
cyclothymic 
    
r=0,517
    

    

    

  
  


    

    
p <0,001
    

    

    

  
  

    
Hyperthymic 
    
r=-0,347
    
r=-0,195
    

    

  
  

    

    
p=0,013
    
p=0,051
    

    

  
  

    
Irritable 
    
r=0,349
    
r=0,624
    
r=0,025
    

  
  

    

    
p <0,001
    
p <0,001
    
p=0,805
    

  
  

    
Anxious 
    
r=0,537
    
r=0,659
    
r=-0,182
    
r=0,566
  
  

    

    
p <0,001
    
p <0,001
    
p=0,069 
    
p <0,001
  

Table 5:  Inter-tempéramental corrélations.

Discussion

Our study allowed to assess the affective temperaments in a population of patients treated for bipolar disorder type I using the questionnaire TEMPS-A. We searched for correlations between affective temperaments and clinical and evolutionary characteristics. In our study, age was positively correlated to the temperament hyperthymic scores. Thus, the more the patients got older, the more the scores of hyperthymic temperament rose. Our results do not agree with the majority of studies. Indeed, several authors have not objectified correlation between the scores of affective temperaments and the age of bipolar patients. Some authors even report negative correlations between the scores of cyclothymic and hyperthymic temperament and age. However, Brieger and al support the hypothesis that personality is altered by the affective disorder [13]. Indeed, it is now established that the residual states with persistent changes occur not only in the schizoaffective disorder or schizophrenia, but also during the development of mood disorders. Thus this leads to a phenomenon of lasting, residual and chronic phases such as subchronic depressive syndromes or chronic hyperthymia. The type of residual syndrome depends on the evolution of the underlying disorder and previous episodes deviation [14]. This component has been neglected in most studies. Thus, patients who experienced mixed episodes are developing different types of residual states compared to patients who have not had this kind of episodes. Moreover, the probability of having residual states increases with duration of disease progression [13]. This could explain the increase in average scores of hyperthymic temperament with age. In our study, the type of episodes being presented was of mainly manic kind. Therefore, it would probably be chronic hyperthymia states. In our work, irritable and cyclothymic temperaments were positively correlated with smoking. Literature data concerning the correlations between affective temperaments and addictive behavior in bipolar patients are controversial [15-17]. Some authors report that the use of alcohol and other psychoactive substances are more common in bipolar I patients with cyclothymic temperament [7,16,18]. For Hantouche et al, they are the cyclothymic and hyperthymic temperaments which predispose more to substances abuse [15]. In our study, the average score of cyclothymic temperament was positively correlated with the number of mixed episodes. The average score of depressive temperament was positively correlated with previous mixed episodes. Mazzarini et al., find no correlation between the polarity of the predominant episodes in bipolar patients type I and affective temperaments. According to these authors, patients with more depressive episodes and those with more manic episodes have the same characteristics with temperamental predominance of hyperthymic and cyclothymic temperaments in both groups [19]. Affective temperaments seem to be the key to differentiating between unipolar and bipolar patients regardless of the predominant polarity of thymic episodes. On the contrary, Vöhringer et al, found a positive correlation between depressive temperament and the number of depressive episodes [20]. A similar result was reported by Henry et al, in bipolar patients I. These authors also report that the number of manic episodes is positively correlated with the hyperthymic temperament and negatively with the depressive temperament [21]. Moreover, Perugi et al, find that bipolar patients type I with cyclothymic temperament have a greater number of depressive and hypomanic episodes [22]. Indeed cyclothymic temperament rarely associates with typical manic episodes. This temperament is rather correlated with dysphoric mania [15]. Besides, according Kesebir et al, depressive and anxious temperaments are frequently noted in patients who have already experienced mixed episodes, while hyperthymic temperament is less noted in these patients [16]. Similarly, Röttig et al, report positive correlations between depressive, cyclothymic, irritable and anxious temperaments and the previous mixed episode in the bipolar I [23]. These data in the literature emphasize the link between the type of affective temperament and the nature of thymic episodes. Indeed, mania typically derives from the hyperthymic temperament while depression would result from depressive temperament. As for mixed episodes, they would come from the coexistence of a mood episode or and an opposite polarity temperament [23-25]. In our study, the average scores of affective temperaments were negatively correlated with the presence of psychotic features during the first thymic episode for the anxious temperament. In the literature, the results of different studies on the links between affective temperaments and psychotic features remain controversial [23,25-27]. Indeed, Dell’Osso et al, found a negative correlation between hyperthymic temperament and psychotic features incongruent for mood in bipolar I patients [25]. O the contrary, Gassab et al, reported an average score of hyperthymic temperament significantly higher in the presence of a last depressive episode with psychotic features in bipolar patients type I [27]. Kesebir et al, found a positive correlation between the existence of thymic episodes with psychotic features in bipolar patients type I and the presence of irritable temperament [16]. For Akiskal, psychotic features are primarily associated with cyclothymic and irritable temperaments [28]. The same author also reported an association between psychotic features and complex temperamental regulations with depressive, cyclothymic and irritable features in bipolar patients [7]. In our study, a statistically significant negative correlation was found between hyperthymic temperament and depressive temperament. A positive correlation was noted between depressive, cyclothymic, irritable and anxious temperament. These results are consistent with literature data [29-31]. Indeed, Matsumotu et al, in the validation study of the Japanese version of TEMPS-A, reported a positive correlation between depressive, cyclothymic, anxious and irritable temperaments. They reported no statistically significant correlation between hyperthymic temperament and other temperaments [31] The German study by Bloink et al, shows the existence of a statistically significant positive correlation between depressive, cyclothymic, anxious and irritable temperaments. The hyperthymic temperament is negatively correlated with depressive and anxious temperament [29]. Figuera et al, finding a negative correlation between depressive and hyperthymic dimension, conclude that these two areas are united but opposed to the temperamental scale [30]. This can be explained by the fact that affective, depressive and hyperthymic temperaments would be part of a two-phase continuum by analogy with bipolar disorder [32]. Moreover, the strong positive correlation between depressive, cyclothymic, irritable and anxious temperaments allowed to hypothesize the existence of a common superstructure comprising these four temperaments. There would be a common thread between these four temperaments, which is the depressive component, present in different degrees [33]. The hyperthymic temperament would be totally independent of this structure [34]. The works of Gonda et al, provide genetic evidence for this hypothesis. Indeed, they show a significant association between short allele (S) encoding the serotonin transport protein (5HTTLPR) and cyclothymic, anxious, irritable and depressive temperaments. These authors reported no correlation between hyperthymic temperament and this carrier (5HTTLPR) that facilitates the uptake of serotonin in the cerebral amygdala and is involved in the modulation of emotions [35,36]. The prescription of benzodiazepines was significantly correlated with higher average scores in irritable temperament. This prescription was also correlated with higher average scores in cyclothymic temperament but the differences were not significant. In the literature, the links between affective temperaments and therapeutic behaviors have been studied in only a few works. Therefore, the possibility that affective temperaments could predict the effects of different treatments remains controversial. Rybakowski et al, show that the response to lithium therapy is positively correlated to the hyperthymic temperament scores [37,38]. These authors also find a negative correlation between this response and cyclothymic, depressive and anxious temperaments [38]. Indeed, according to Hantouche et al, it would be possible, theoretically, to stipulate that the mania results from the interaction of excessive energy of hyperthymic temperament with exogenous inducing factors. In this model, the stabilizing effect of lithium may be related to an attenuator effect of hyperthymia, thereby protecting the subject against the occurrence of manic episodes. Camacho et al, recommend anticonvulsants in bipolar having a substance abuse for their action on the underlying temperament especially in case of cyclothymic and hyperthymic temperaments [39]. Lasevoli et al, report a more frequent prescription of conventional neuroleptics in case of the cyclothymic and hyperthymic temperaments. In the same study benzodiazepines are prescribed for bipolar having hyperthymic temperament with alcohol dependence. The prescription of benzodiazepines is also more frequent in case of the most recent episode of mixed type [40]. However, these authors found that treatment choices are weakly influenced by the different temperaments and / or type of episode. Therefore, they do not identify differences in the therapeutic management of bipolar patients based on affective temperaments. Concerning the prescription of antidepressants, literature data underline a hyperthymic temperament that promotes a manic turn in bipolar patients [41,42]. Akiskal also stresses that the temperamental model of bipolar disorder is not without consequences therapeutically. The central idea in this area is that the temperament is the basis and the starting point, as well as the end point of thymic episodes. Thus the risk of a too aggressive treatment episodes is jeopardizing what is unique about such an individual patient as well as its intercritical terms of operation [43].

Study Limitations

The Cross-cutting nature: the evaluation of affective temperaments was performed after remission of the disorder without its ability to evaluate them in pre morbid. A longitudinal assessment would be interesting to objectify the stability of different temperaments.

The Selection of our hospital exclusively sample may be biased, insofar the disorders encountered in this context are probably more severe.

To Identify subjects in thymic relapse we are based on the psychiatric interview. Rating scales were not used due to the length of the questionnaire. To minimize bias in assessment, the same examiner assured the collection of epidemiological data, the passing of TEMPS-A and data entry.

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