Research reportRelationship between affective temperaments and aggression in euthymic patients with bipolar mood disorder and major depressive disorder
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 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 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.
Section snippets
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
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
Discussion
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) 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
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
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.
References (46)
- et al.
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.
(2005) - et al.
Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN)
J. Affect. Disord.
(1998) - et al.
TEMPS-A: validation of a short cersion of a self-rated instrument designed to measure variations in temperament
J. Affect. Disord.
(2005) - et al.
The evolving bipolar spectrum. Prototypes I, II, III, and IV
Psychiatr. Clin. N. Am.
(1999) - et al.
The theoretical underpinnings of affective temperaments: implications for evolutionary foundations of bipolarity and human nature
J. Affect. Disord.
(2005) - et al.
Factorial structure and internal consistency of the German TEMPS-A scale: validation against the NEO-FFI questionnaire
J. Affect. Disord.
(2005) - et al.
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.
(2003) - et al.
Polish validation of the TEMPS-A: the profile of affective temperaments in a college student population
J. Affect. Disord.
(2010) - et al.
Symptom profile consistency in recurrent manic episodes
Compr. Psychiatry
(2002) - et al.
Findings from the National Comorbidity Survey on the frequency of violent behavior in individuals with psychiatric disorders
Psychiatry Res.
(2005)
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.
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.
Clinical risk factors for bipolar disorders: a systematic review of prospective studies
J. Affect. Disord.
Towards a genetically validated new affective temperament scale: a delineation of the temperament phenotype of 5-HTTLPR using the TEMPS-A
J. Affect. Disord.
Criminal behaviour and violent crimes in former inpatients with affective disorder
J. Affect. Disord.
Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multisite study (EPIDEP)
J. Affect. Disord.
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
Do prior histories of violence and mental disorders impact on violent behaviour during encounters with police?
Int. J. Law Psychiatry
Reliability and validity of TEMPS-A in a Japanese non-clinical population: application to unipolar and bipolar depressives
J. Affect. Disord.
Predominant polarity and temperament in bipolar and unipolar affective disorders
J. Affect. Disord.
A comparison of recovered bipolar patients, healthy relatives of bipolar probands, and normal controls using the short TEMPS-A
J. Affect. Disord.
Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters
J. Affect. Disord.
Impulsivity, aggression and suicidal behavior in unipolar and bipolar disorders
J. Affect. Disord.
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