\PERGAMON Journal of Psychiatric Research 22 "0888# 20Ð25

9911Ð2845:88:, ! see front matter Þ 0888 Published by Elsevier Science Ltd[ All rights reserved[PII] S 9 9 1 1 Ð 2 8 4 5 " 8 7 # 9 9 9 2 5 Ð 2

Temperament and character inventory "TCI# and depressionMichel Hansenne�\ Jean Reggers\ Emmanuel Pinto\ Karim Kjiri\ Amar Ajamier\

Marc AnsseauPsychiatric Unit\ Centre Hospitalier Universitaire du Sart Tilnan "B!24#\ B!3999 Lie�`e\ Bel`ium

Received 11 April 0887^ received in revised form 04 June 0887^ accepted 10 July 0887

Abstract

Although several studies have assessed the relationships between the temperament dimensions of the Cloninger model of personalityand depression\ little is known about the role played by the character dimensions proposed by the seven!factor model of Cloningerin depression[ In this study\ the relationships between the Temperament and Character Inventory "TCI# and depression wereexamined in a sample of 39 major depressive patients and 39 healthy controls[ Depressed patients exhibit higher harm avoidanceand self!transcendence scores as well as lower self!directedness and cooperativeness scores as compared to healthy controls[ However\the three other dimensions do not di}er between depressive patients and controls[ Among the depressive group\ harm avoidance\self!directedness and cooperativeness dimensions are related to the severity of depression as assessed by the Hamilton scale[ Thisstudy con_rms the state dependence of the harm avoidance dimension and suggests a relationship between the character dimensionsof the Cloninger model and depression[ Þ 0888 Elsevier Science Ltd[ All rights reserved[

0[ Introduction

Over the past decade\ Cloninger and his colleagueshave developed a biosocial model of personality basedon three fundamental dimensions] novelty seeking\ harmavoidance and reward dependence "Cloninger\ 0875\0876#[ Novelty seeking is de_ned as the tendency torespond actively to novel stimuli leading to pursuit ofrewards and escape from punishment[ Harm avoidancecorresponds to the tendency toward an inhibitoryresponse to signals of aversive stimuli that lead to avoid!ance of punishment and non!reward[ Reward dependenceis de_ned as the tendency for a positive response to signalsof reward to maintain or resist behavioral extinction[According to this model\ the three dimensions have beenpostulated to be inheritable and independent[ Moreover\each dimension has been related to a speci_c centralneurotransmitter^ novelty seeking to dopaminergicactivity^ harm avoidance to serotonergic activity^ andreward dependence to noradrenergic activity[ Factorialanalysis reported a good validation of novelty seekingand harm avoidance\ but a poorer validation for rewarddependence "Cloninger et al[\ 0880^ Svrakic et al[\ 0880^Wetzel et al[\ 0881^ Le�pine et al[\ 0883#[ The Tri!dimensional Personality Questionnaire "TPQ# has been

� Corresponding author[ Tel[] 9921 3255 6859^ fax] 9921 3255 6172^e!mail] michel[hansenneÝulg[ac[be[

developed by Cloninger to assess these temperaments"Cloninger et al[\ 0880#[

Recent work from Cloninger et al[ "0880\ 0882# havesuggested that reward dependence must be separated intwo dimensions^ isolating persistence dimension andregrouping the three other subscales in a reward depen!dence dimension[ Moreover\ the model was recentlyextended to measure seven dimensions of personality withthe addition of three measures of character] self!directed!ness\ cooperativeness and self!transcendence "Cloningeret al[\ 0882^ Svrakic et al[\ 0882#[ This extension is basedon a synthesis of information about social and cognitivedevelopment and descriptions of personality develop!ment in humanist and transpersonal psychology[ Theseven!factor model supersedes models with fewer factorslike the big!_ve model of personality "Digman\ 0889# orthe classic three model of Eysenck "0880# as well as themodel of Zuckerman "0883#[ Self!directedness refers tothe ability of an individual to control\ regulate and adapthis behavior to _t the situation in accord with individuallychosen goals and values[ The second character dimensionof cooperativeness was formulated to account for indivi!dual di}erences in identi_cation with and acceptance ofother people[ Cooperative individuals are described associally tolerant\ empathic\ helpful and compassionate\whereas uncooperative individuals are described associally intolerant\ disinterested in other people\ unhelpfuland revengeful[ Self!transcendence is a character associ!ated with spirituality\ and refers generally to identi_cation

M[ Hansenne et al[ : Journal of Psychiatric Research 22 "0888# 20Ð2521

with everything conceived as essential and consequentialparts of a uni_ed whole[ The Temperament and CharacterInventory "TCI# is a 115!item self!questionnaire developedby Cloninger et al[ "0883# to assess the seven dimensionsof personality[

The relationship between personality and depression isextremely complex] Personality features may predisposean individual to depression^ the personality can be modi!_ed after a depression^ the personality can modify theclinical presentation of a depressive disorder^ and _nallythe personality can be considered like a subclinical mani!festation of a depressive disorder "Akiskal et al[\ 0872^Hirschfeld et al[\ 0886#[

Concerning the TPQ\ several studies have demon!strated that harm avoidance\ but not novelty seekingand reward dependence dimensions\ may be related todepression "Strakowski et al[\ 0881\ 0884^ Brown et al[\0881^ Wetzel et al[\ 0881^ Jo}e et al[\ 0882^ Le�pine et al[\0883^ Nelson and Cloninger\ 0884^ Chien and Dunner\0885\ Hansenne et al[\ 0886#[ Recently we have reportedthat the novelty seeking subscale exploratory excitability"NS0# score was lower in depressive inpatients as com!pared to controls "Hansenne et al[\ 0887#[ However\ littleis known about the role played by the character dimen!sions proposed by the seven!factor model of Cloningerin depression[ Black and Sheline "0886# have reportedthat the self!directedness score increase after successfulpharmacotherapy of the depressive disorder\ and theresults of the study of Tome et al[ "0886# have suggestedthat temperament factors of the TCI may in~uence theoutcome of antidepressant treatment[ Bayon et al[ "0885#have demonstrated that the TCI self!directedness scoresof a sample of psychiatric outpatients were lower as com!pared to the scores of a general community sample[ Theseresults suggest that the self!directedness character couldbe\ like harm avoidance\ state!dependent[ However\ thesestudies did not include a control group[ Therefore\ wecarried out a systematic evaluation of TCI scores indepressive inpatients and controls[

1[ Methods

The study was conducted in 39 depressive inpatientsadmitted in the Psychiatric Unit of the University Hos!pital of Lie�ge "Belgium#[ The sample comprised 12women and 06 men with a mean age of 24[6 years"SD�8[5#[ All diagnostic assessments were performedby two psychiatrists "EP and KJ#\ and clinical ratings bythe same psychologist "MH#[ All patients met the criteriafor major depressive disorder according to the DSM!IV"APA\ 0883#\ with a score of at least 07 on the 06!itemHamilton depression scale "Hamilton\ 0856#[ Thepatients do not present concurrent DSM!IV axis Idisorder\ and the personality disorders as described inDSM!IV axis II have not been assessed[ The patients

were free of medical illness\ evidenced by clinical exam!ination\ history\ electrocardiogram "ECG#\ electro!encephalogram "EEG#\ chest X!ray\ and routine lab!oratory tests[ For avoided age and gender e}ects\ thecontrol group was matched for age and gender with thedepressive group[ The mean age was 22[8 years"SD27[2#[ They have been recruited among the sta}from the University Hospital of Lie�ge[ They all under!went a medical interview to exclude psychiatric orsomatic disorders[ They had a score lower than 7 on the06!item Hamilton depression scale\ with a mean of 0[7"SD�0[46# and a score lower than 1 on item 0[ Thedepressed patients completed a French version of the115!item self questionnaire TCI during the _rst days ofthe hospitalization\ and the control group had receivedthe instruction to complete the questionnaire at home[The translated version of the TCI used in the study hasbeen recommended by Cloninger[ It has been performedby Te�he�rani and Le�pine and validated by Pe�lissolo andLe�pine "0886#[ The investigation was carried out inaccordance with the latest version of the Declaration ofHelsinki\ and the protocol was approved by the EthicalCommittee of the University of Lie�ge Medical Schooland all subjects gave their informed consent[

All the statistical analyses were performed using Stat!istica "3[4# for Windows "Statsoft Inc[\ 0882#[ Di}erenceson TCI dimensions and sub!scales between the patientsample and the control group were examined with mul!tivariate analysis of variance "Manova#\ with TCI scoresas dependent variables and group "depressed:controls#\gender as independent variables\ and age as cofactors[Within!group correlations between TCI scores were doneusing the Pearson|s correlation coe.cient[ Among thedepressed group\ the relationship between Hamiltonscores and the TCI were also performed by Pearson|scorrelation coe.cients[ A two!tailed level of signi_canceof 4) was adopted for multivariate analysis and 0) forcorrelation coe.cients[

2[ Results

The mean scores for each of the seven personality scalesand their subscales are presented in Table 0 for bothdepressed and control groups[ Multivariate analysisshowed that depressed patients exhibited statistically sig!ni_cant higher scores for harm avoidance and self!tran!scendence dimensions and lower scores for self!directed!ness and cooperativeness dimensions as compared to con!trols[ For harm avoidance and self!transcendence dimen!sions\ all the subscale scores were higher\ whereas thatfor cooperativeness and self!directedness\ some subscalesdid not di}er between the two groups "respectively CO3\CO4 and SD3#[ On contrary\ the two groups did not di}erfor novelty seeking\ reward dependence and persistence

M[ Hansenne et al[ : Journal of Psychiatric Research 22 "0888# 20Ð25 22

Table 0Comparison of personality dimensions between depressive "n � 39# and control "n � 39# subjects[ Data are shown as mean2SD\ with analysis ofvariance results for the group factor

TCI Dimensions Controls Depressed ANOVAs F "df � 0\64# P

Novelty Seeking "NS# 19[125[7 07[925[1 1[5 9[00NS0 5[521[4 3[421[4 09[6 9[990NS1 3[121[0 3[321[1 9[90 9[51NS2 4[021[7 3[721[1 9[13 9[51NS3 3[220[5 3[120[6 9[14 9[50

Harm Avoidance "HA# 02[324[8 14[524[5 68[7 ³9[990HA0 2[621[1 6[821[4 52[0 ³9[990HA1 2[520[7 4[920[6 00[1 9[990HA2 2[221[3 4[421[0 04[7 ³9[990HA3 1[520[5 6[020[8 033[8 ³9[990

Reward dependence "RD# 05[723[0 04[323[3 0[5 9[19RD0 5[720[2 6[420[8 1[5 9[09RD2 5[921[9 3[321[3 6[1 9[997RD3 2[520[3 2[420[5 9[91 9[77

Persistence 2[821[4 3[021[3 9[1 9[55

Self!Directedness "SD# 22[224[3 11[327[5 31[0 ³9[990SD0 6[120[1 2[521[4 62[5 ³9[990SD1 5[220[8 2[621[0 18[3 ³9[990SD2 3[129[8 1[020[3 38[7 ³9[990SD3 7[321[8 6[521[6 0[7 9[07SD4 6[221[1 4[021[5 00[3 9[990

Cooperativeness "CO# 20[823[2 17[224[7 7[3 9[993CO0 5[529[7 4[220[6 08[1 ³9[990CO1 4[320[2 3[420[3 09[5 9[990CO2 5[220[2 4[023[5 00[1 9[990CO3 6[421[2 6[921[6 9[6 9[28CO4 5[120[4 5[220[3 9[93 9[72

Self!transcendence "ST# 09[124[9 03[425[1 6[4 9[996ST0 3[221[2 5[921[4 6[4 9[996ST1 1[120[7 2[321[0 3[6 9[92ST2 2[621[2 4[022[0 2[2 9[96

dimensions\ except a lower score of the NS0 and RD2subscales in depressive patients[

Main e}ects of sex were signi_cant for harm avoidance\self!directedness and self!transcendence dimensions[Harm avoidance and self!transcendence scores werehigher for females[ On contrary\ self!directedness scoreswere lower in females[ Concerning the subscales\ theHA0\ HA3\ ST0\ ST2 and CO2 scores were higher infemales\ whereas SD0\ SD2\ SD3 and CO1 were lower infemales[ Multivariate analysis showed that group"depressed:controls#×sex interaction was signi_cant foronly self!directedness dimension[ Concerning subscales\group×sex interactions were signi_cant for SD0\ SD4\HA3 and ST2[

Among the group of depressed inpatients\ the Ham!ilton scale was signi_cantly correlated with harm avoid!ance "r�9[36\ P�9[991#\ self!directedness "r�−9[37\P�9[991#\ co!operativeness dimensions "r�−9[31\P�9[996#\ but not with novelty seeking "r�−9[92\

P�9[71#\ reward dependence "r�−[08\ P�9[11#\ self!transcendence "r�9[29\ P�9[94# and persistencedimensions "r�−9[04\ P�9[24#[ For the controlgroup\ no relationship reached the level of signi_cance[The correlations between TCI dimensions and the agewere not signi_cant in both groups[

The correlations among the four dimensions of tem!perament and the three dimensions of character indepressed and healthy group are summarized respectivelyin Table 1 and 2[ Within the depressed group\ the sig!ni_cant correlations relate harm avoidance with self!directedness and self!transcendence\ and cooperativenesswith reward dependence[ Within the control group\ thesigni_cant correlations relate harm avoidance with noveltyseeking\ and cooperativeness with novelty seeking andharm avoidance[

We have further divided the TCI scores of thedepressed sample between high and low using a mediansplit of each dimension scores based on the control scores

M[ Hansenne et al[ : Journal of Psychiatric Research 22 "0888# 20Ð2523

Table 1Correlations among temperament and character scales within thedepressed group

NS HA RD P SD CO

NS * * * * * *HA −9[19 * * * * *RD 9[90 −9[00 * * * *P −9[16 −9[06 9[19 * * *SD −9[921 −9[45 −9[92 9[22 * *CO 9[97 −9[20 9[37 9[00 9[23 *ST 9[91 9[18 9[16 9[92 −9[33 −9[95

Bold coe.cients are signi_cant at P ³ 9[90[ NS indicates novelty seek!ing^ HA\ harm avoidance^ RD\ reward dependence^ P\ persistence^ SD\self!directedness^ CO\ cooperativeness^ ST\ self!transcendence[

Table 2Correlations among temperament and character scales within the con!trol group

NS HA RD P SD CO

NS * * * * * *HA −9[47 * * * * *RD 9[91 9[12 * * * *P −9[28 9[10 9[17 * * *SD −9[92 −9[24 −9[04 9[98 * *CO 9[35 −9[40 9[11 9[04 9[21 *ST 9[96 −9[97 9[95 9[15 −9[06 9[12

Bold coe.cients are signi_cant at P ³ 9[90[ NS indicates novelty seek!ing^ HA\ harm avoidance^ RD\ reward dependence^ P\ persistence^ SD\self!directedness^ CO\ cooperativeness^ ST\ self!transcendence[

as the criterion for group membership[ The results arepresented in Table 3[ When looking at this table\ wecan see that depressive patients have the schizotypicalcon_guration described by Cloninger and Svrakic "0886#[

Table 3Number of depressed patients which have low or high TCI dimensionscores according to the median scores of control group

Low High

NS 18 00HA 0 28RD 15 03P 11 07SD 27 1CO 29 09ST 00 18

NS indicates novelty seeking^ HA\ harm avoidance^ RD\ reward depen!dence^ P\ persistence^ SD\ self!directedness^ CO\ cooperativeness^ ST\self!transcendence[

3[ Discussion

The main _ndings of the present study are thatdepressed patients exhibit lower self!directedness and co!operativeness scores and higher harm avoidance and self!transcendence scores as compared to healthy controls[ Inaddition\ their levels of self!directedness\ cooperative!ness\ and harm avoidance appear to be related with theseverity of depressive symptomatology[ These resultscon_rm an association between self!directedness dimen!sion and depressive state reported in a recent study byBlack and Sheline "0886#[ They indicate that cooperative!ness dimension is also dependent from the clinical statusof the depressed patients[ This study also con_rms theclinical dependence of harm avoidance dimension pre!viously described by di}erent groups "Brown et al[\ 0881^Wetzel et al[\ 0881^ Jo}e et al[\ 0882^ Le�pine et al[\ 0883^Strakowski et al[\ 0884^ Nelson and Cloninger\ 0884^Chien and Dunner\ 0885#[ Finally\ the present study con!_rms that the TCI scales are weakly related among them!selves[ The relationships observed are consistent withthose reported by Cloninger et al[ "0882#[

Cloninger and his colleagues have reported that lowerscores of self!directedness and cooperativeness dimen!sions predicted the presence of a personality disorder bydi}erentiating patients varying from 00Ð83) "Cloningeret al[\ 0882^ Svrakic et al[\ 0882^ Bayon et al[\ 0885#[ Onthe other hand\ the TCI self!transcendence dimensionwas associated with psychotic features\ and could be con!sidered for a risk of general psychopathology[ Higherself!transcendence scores when combined with gooddevelopment on the two other character dimensions areassociated with mature creativity[ However\ after Clon!inger\ when combined with poor development of oneor both of the other character dimensions\ higher self!transcendence scores are associated with proneness topsychosis[ Then\ the results of the present study showthat depressed patients exhibited a TCI pro_le which iscompared to personality disorder subjects with a prone!ness to psychosis\ and corresponds to the schizotypicalcon_guration described by Cloninger and Svrakic "0886#[

In fact\ several studies have demonstrated thatdepressed patients often present an associated personalitydisorder "Charney et al[\ 0870\ Sandersson et al[\ 0881\Mulder et al[\ 0883#[ After these studies\ the rate of apersonality disorder associated with a depressed episoderanged from 8Ð77)[ It should be noted that personalitydisorders observed in depressed patients may be a func!tion of state and may normalize with recovery[ Indeed\Loranger et al[ "0880# have reported that depressedpatients exhibit fewer maladaptive personality traits atfollow!up than at entry[ However\ since the personalitydisorders of the depressed patients have been not assessedin the present study\ we are not able to verify this point[On the other hand\ lower scores of self!directedness andcooperativeness dimensions and higher scores of self!

M[ Hansenne et al[ : Journal of Psychiatric Research 22 "0888# 20Ð25 24

transcendence could re~ect a general psychopathologynot speci_c to depression[

Several studies reported signi_cant relationshipsbetween depression and the harm avoidance dimensionof the TPQ "Wetzel et al[\ 0881^ Jo}e et al[\ 0882^ Le�pineet al[\ 0883^ Nelson and Cloninger\ 0884^ Strakowski etal[\ 0884\ Hansenne et al[\ 0886#[ Contrary to noveltyseeking and reward dependence dimensions which remainstable in patients with major depression over time\ harmavoidance appears to be a measure which is elevatedduring depressive states and which appears to changetoward control values with improvement of depression"Mulder and Joyce\ 0883^ Chien and Dunner\ 0885#[Moreover\ Mulder and Joyce "0883# have reported a sig!ni_cant di}erence between harm avoidance scoresassessed initially and after six weeks of antidepressanttreatment[ In the present study\ we con_rm a signi_cantassociation between this dimension and the severity ofdepression as assessed by the Hamilton depression scale[Thus\ harm avoidance is state dependent in depression[However\ the higher score of harm avoidance is not spec!i_c to depression since the same result has been observedin other clinical states like obsessive compulsive disorder"Pfohl et al[\ 0889#\ panic disorder "Starcevic et al[\ 0885#posttraumatic stress disorder "Wang et al[\ 0886# andschizophrenia "Van Ammers et al[\ 0886#[ Thus\ higherscore on this dimension could re~ect the severity of gen!eral psychopathology and could constitute a personalityrisk to develop a mental disorder\ except for the antisocialpersonality disorder\ in which harm avoidance scores arelow[

In the present study\ the novelty seeking subscaleexploratory excitability "NS0# is lower among thedepressive group as compared to the controls[ This resultis of interest since many studies have reported that nov!elty seeking was not a}ected by clinical state of depressedpatients "Brown et al[\ 0881^ Svrakic et al[\ 0881^ Le�pineet al[\ 0883^ Chien and Dunner\ 0885#[ However\ recently\Nelsen and Dunner "0884# have shown that treatment!resistant patients had a lower score on the novelty seekingdimension than non!treatment resistant patient[ Thelower score observed in the present study concerning theNS0 subscale in the depressed group could correspondto the di.culty for depressed patients to initiate novelbehavior and to produce active exploration of theenvironment[ This result could be a consequence of thechronicity of depression rather than its cause[

Gender di}erences concerning the temperament andthe character dimensions have been assessed in severalstudies "Cloninger et al[\ 0880\ 0882^ Brown et al[\ 0881#[These studies have been reported that men tending tohave higher novelty seeking scores and lower harm avoid!ance and cooperativeness scores as well as reward depen!dence scores than women[ In our study\ we have notreported the same di}erences[ Indeed\ the results show amain gender e}ect for harm avoidance\ self!directedness

and self!transcendence\ and a signi_cant group×genderinteraction for self!directedness[ This interaction couldsuggest that depression a}ect di}erentially the self!direct!edness dimension in men and in women[

Several studies have demonstrated that some dimen!sions\ and more particularly the novelty seeking dimen!sion\ varied with age "Cloninger et al[\ 0880\ Le�pine etal[\ 0883#[ In fact\ novelty seeking scores are reduced withage[ Moreover\ self!directedness and cooperativeness arereported to have a strong correlation with age "Cloningeret al[\ 0882#[ However\ we have not reported a relationbetween age and the TCI dimensions[ The negative resultscould be explained by the lower mean age in our sample[

In conclusion\ the study con_rms a link betweendepression and harm avoidance dimension of the TCIand suggests additional relationships with the characterdimensions of self!directedness and cooperativeness ofthe Cloninger model of personality[ However\ it shouldbe acknowledged that the study was carried out with arelatively small sample[ Therefore\ the conclusionsshould be not considered as de_nitive and further studiesshould be conducted with larger sample of patients[

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