Are there temperament differences between major depression and dysthymic disorder in adolescent clinical outpatients?
Introduction
Although the temperament and personality background, that is, the correlates of adult depressive syndromes are well researched, evidence of the related temperament and character traits regarding preadolescent-adolescent depression has only recently begun to accumulate [1], [2], [3], [4]. Apart from the clinical studies of bipolar disorder [5], [6], [7], most research activities have no clinical specification of depression and are diverse in aspects and conclusions.
Charbonneau et al [8] proved the moderating effect of emotional reactivity between life stressors and depression. The study of Betts et al [9]—using a self-report depression scale—confirmed that low-level positive moods, inflexibility, diminished approach behaviors and emotional dysregulation are significantly associated with the presence of high depressive symptom. Examining the emotional regulation of depressive children using multivariate models, Tortella-Feliu et al [10] found that negative affectivity and negative emotional regulation—although mediated by anxiety—played a determining role in the depressive symptom in a large adolescent sample. Among the few clinical surveys, Tamas et al [4] confirmed that high maladaptive and low adaptive emotional regulation response tendencies increase the odds of suicidal behaviors, above and beyond the risk posed by the severity of depressive illness. The research regarding syndromes and accompanying temperament traits is of clinical importance as comorbid personality disorders may make the clinical diagnosis more difficult, may worsen the process or outcome, and may reduce the patients' opportunities for therapy. Rihmer [11] points the increased risk of suicide risk of mood episodes if they associate with comorbid personality disorders.
The psychobiologic model of Cloninger [12] is a systematic method used worldwide in community studies and clinical samples for clinical description and classification of both normal and abnormal personality variants. The self-report Temperament and Character Inventory (TCI) based on this model has been of great clinical relevance, as it differentiates between 2 main vectors of personality, temperament and character, and it includes 4 temperament and 3 character dimensions [13], [14], [15].
The temperament scale of the TCI has 4 independent dimensions1: (a) novelty seeking (NS), (b) harm avoidance (HA), (c) reward dependence (RD), and (d) persistence (P). The 3 factors on the character scale are (I) self-directedness (SD), (II) cooperativeness (C), and (III) the dimension of self-transcendence (ST).
Pelissolo and Corruble [16] summarized the usefulness of the TCI to explore personality factors associated with adult depressive disorders. They established that depression is significantly associated with decreased NS and SD and with increased HA and RD. Major depression seems to be associated with increased HA and ST [17] but with low RD, SD, and C.
The 105-item preschool version of the method and the junior version of the TCI (Junior Temperament and Character Inventory [JTCI] [18]) with the original factor structure seem useful in tracing the origins of personality variations to early childhood and adolescence.
In a Korean community-based study, Kim et al [19] noted that self-reported psychopathology in adolescents is significantly associated with the specific temperament and character constellations of the JTCI of Cloninger [12]. Internalizing problems from the Youth Self Report questionnaire (the withdrawn, somatic complaint, and anxious/depressed scale of the Youth Self Report) were significantly related to high HA and low RD and SD.
However, eminent researchers [11], [20], [21], [22], [23], [24] present a continuum or spectrum theory of depressive disorders. The use of epidemiological and prospective clinical follow-up studies documents the course of major depressive disorder (MDD) expressing a fluctuation of intensity, activity, and severity of symptoms including remarkable sways in psychosocial functioning, too. According to the prospective observation of Kovacs et al [24], “dysthymia” serves as a precursor of major affective episodes in up to 80%. If subsyndromal forms of depression ranging from minor depression, through dysthymic disorder (DD), to subthreshold depression are not discrete disorders but stages of symptomatic phases of MDD, the DD is only a milder symptomatic level during the course of a major depression; and there is no reason to examine temperament differences between subtypes. Scarce differences between MDD and DD [23] and the fact that patients have frequently changing clinical diagnoses regarding subtypes argue in favor of the spectrum theory of depressive disorders, too.
As the borderline personality disorder is often associated with minor, subthreshold, “low-grade,” subsyndromal affective symptoms and/or with comorbid dysthymic or bipolar II disorder, it is obvious that bipolar disorder could have been provided as basic temperament denominator of “atypical” depressives. However, the construct “borderline” was too vague and heterogenous [20] to specify 1 certain depression subtype, namely, DD. The terms anxious-sensitive temperament or hysteroid-dysphoric character seem to enhance the terminological confusion; and even, dysthymia is used as subtype of the depressive spectrum as well as a “temperament subtype” of the same among irritable and cyclothymic types, too [25].
The differences in clinical symptoms, sequelae, outcome, the lower suicide risk, and frequently dissimilar relationships of the self to the DD (“I have been depressed all of my life”) make it not unwise to examine possible character differences between the 2 clinical disorders of depression. Still, if we found no temperament difference(s) or only a few character dissimilarities between MDD and DD, the results may reinforce the continuum theory of depressive disorders.
The aim of the study was to explore whether there are differences in temperament and character traits between MDD and DD in Hungarian depressive adolescent outpatients. Based on the literature of adult and adolescent depression, it is hypothesized that adolescent patients with a diagnosis of major depression (group I) will present (1) lower NS but will have (2) an increased HA, coupled with a (3) lower level of SD, (4) P, and (5) C compared with identical JTCI scales of their dysthymic (DD) peers (group II). From the clinical perspective, the latter maintain more from their psychosocial functioning in most aspects (learning/work), which is why we assumed that there would be more favorable qualities in the group of dysthymic youngsters.
Section snippets
Sample
All the cases were selected from a larger mother sample (Pannonia survey, see Csorba et al [26]) including 169 outpatients with diagnoses of depression confirmed by the Mini International Neuropsychiatric Interview (M.I.N.I.), the multisite patient recruitment resulting in 2 specially focused samples participating in the study.
A written consent form was administered describing the aims of the survey and of the procedure stressing the right of denial of both the patient and/or his/her
Results
As seen in the Table 1, only 1 significant difference was found (HA, P = .001). Adolescents with MDD had more efforts (approximately 5%-26%, with in an average with 15% more) in avoiding harmful influences than the members of group II. If a depressive adolescent showed a higher level of HA temperament trait, she/he was more likely (greater odds) to fall into the group I, MDD diagnostic cell than into the DD subsample. No other expectations were proved, as no differences were revealed in other
Discussion
Our adolescents with MDD tended to avoid harmful experiences showing increased shy, worry, and anxious-inhibited behavior more than their DD peers. Although most authors accept that mood disorders are associated with higher HA, literature yields controversial results related to RD in depressive and suicidal samples [17], [31], [32], [33], [34]; and so, we did not make any hypotheses regarding RD. We failed to detect any differences between the 2 groups in SD and ST, the variables most sensitive
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