Journal of Affective Disorders 70 (2002) 219–223www.elsevier.com/ locate/ jad

Brief report

The temperament and character inventory in major depression

a a a a,b ,*G. Marijnissen , S. Tuinier , A.E.S. Sijben , W.M.A. VerhoevenaVincent van Gogh Institute for Psychiatry, Stationsweg 46, 5803AC Venray, The NetherlandsbErasmus University, Faculty of Medicine and Medical Sciences, Rotterdam, The Netherlands

Received 27 June 2000; received in revised form 28 March 2001; accepted 9 April 2001

Abstract

Patients admitted for pharmacological treatment of a non-bipolar major depressive episode completed the Temperamentand Character Inventory (TCI) prior to and after at least 6 weeks of treatment. Treatment with various antidepressantsresulted in a 43% reduction of symptomatology. Scores on the harm avoidance dimension before and after treatmentappeared to be significantly higher as compared to Dutch normative data. TCI scores did not predict response to treatment orshow a change during treatment. It is concluded that, in this group of patients, the personality dimension harm avoidance is atrait factor without predictive value for antidepressant responsiveness. 2002 Elsevier Science B.V. All rights reserved.

Keywords: Major depression; TCI; Harm avoidance; Antidepressant responsiveness

1. Introduction temperament dimensions are assumed to be indepen-dently heritable to a great extent (Cloninger et al.,

Over the past 15 years, Cloninger and associates 1993; Cloninger, 1994). To assess these sevenhave developed a psychobiological model of the dimensions of personality, the Temperament andstructure and development of personality that ac- Character Inventory (TCI) was developed (Cloningercounts for dimensions of both temperament and et al., 1994), which was subsequently translated andcharacter (Cloninger, 1986, 1987, 1988; Cloninger et validated in several languages, including Dutchal., 1993). From extensive research, four dimensions (Duijsens et al., 1997). The TCI is a self-reportof temperament — novelty seeking (NS), harm inventory comprising a total of 240 true or falseavoidance (HA), reward dependence (RD) and per- questions and is the successor of the Three Dimen-sistence (P) — as well as three dimensions of sional Personality Questionnaire (TPQ) which origi-character — self-directedness (SD), cooperativeness nally comprised a set of 90 items. The TPQ covers(C) and self-transcendence (ST) — emerged. The the temperament dimensions NS, HA and RD,

whereas the TCI also includes the fourth tempera-ment dimension P as well as the three characterdimensions. Correlations between TPQ and TCI*Corresponding author. Vincent van Gogh Institute for Psychi-

atry, Stationsweg 46, 5803 AC Venray, The Netherlands. temperament dimension scores have been found to

0165-0327/02/$ – see front matter 2002 Elsevier Science B.V. All rights reserved.PI I : S0165-0327( 01 )00364-0

220 G. Marijnissen et al. / Journal of Affective Disorders 70 (2002) 219–223

be high (NS, 0.971; HA, 0.997; and RD, 0.932) from all analyses due to missing data. The remaining(Cloninger et al., 1994). sample comprised 23 women and 12 men with a

During the nineties, several investigators reported mean age (6S.D.) of 51.3 (614.9) years (rangean association between mood symptoms and scores 23–75 years). Thirteen patients were hospitalized foron the HA dimension of the TPQ. Svrakic et al. a first episode of a depressive disorder; the other 22(1992) and Tanaka et al. (1998) found HA to covary were suffering from a relapsing course with a meanwith mood and anxiety in normal volunteers. Sub- of three prior depressive episodes (range 1–10sequently, Strakowski et al. (1992, 1995) reported a episodes). All patients were admitted to the Vincentpositive correlation between HA and comorbid de- van Gogh Institute for Psychiatry over the periodpressive symptomatology in psychotic disorders. In March 1988–March 1999 and met the criteria foraddition, Joffe et al. (1993) demonstrated higher major depressive disorder according to DSM-IVscores on HA in patients with major depression (American Psychiatric Association, 1994). Onlybefore and after successful treatment with antidepres- three patients also fulfilled the criteria for a per-sants. In general, HA is positively correlated with sonality disorder. All diagnostic assessments weremood, symptoms of anxiety and anxious personality performed by two independent psychiatrists.disorders (Ampollini et al., 1999; Richter et al., Depressive symptomatology was rated with the2000; Brody et al., 2000; Hellerstein et al., 2000; 21-item Hamilton Depression Rating Scale (HDRS;Naito et al., 2000). The state versus trait issue was Hamilton, 1960, 1967) and the Montgomery Asbergfurther investigated by Chien and Dunner (1996), Depression Rating Scale (MADRS; Montgomery andwho also found increased HA scores in depressed Asberg, 1997). The two scales were used concurrent-patients which, however, moved towards values of ly because the HDRS has more anxiety-related itemsnormal controls upon successful treatment. From and the MADRS is more sensitive to changes inthese data they concluded that the HA dimension has severity (Snaith, 1993, 1996). The patients com-both state and trait components, which is in agree- pleted the Dutch version of the TCI.ment with the results reported by Brown et al. HDRS, MADRS and TCI were completed in the(1992). Comparable data were obtained by Hansenne first week of hospitalization, before the start ofet al. (1998, 1999) and Osher et al. (1996). The treatment with antidepressants, and after at least 6results of more recent studies suggest that the HA weeks of medication. At baseline and endpoint, thedimension is state dependent in mood and anxiety severity of depressive symptomatology was assesseddisorders (Allgulander et al., 1998; Brody et al., with the HDRS as well as with the MADRS and was2000; Hellerstein et al., 2000; Naito et al., 2000; correlated with the TCI dimensions. The presentRichter et al., 2000). Concerning treatment outcome, study was not designed to evaluate treatment effects.limited data are available suggestive for a predictive Therefore, the conventional inclusion and responsevalue of certain personality dimensions like HA criteria were not relevant. The choices of the antide-(Joyce et al., 1994; Nelson and Cloninger, 1995, pressive compound and dosages were made by the1997; Nelsen and Dunner, 1995). treating psychiatrist, independent of the study.

The present study was designed to investigate the Because of the relatively small number of patientsassociation between personality dimensions and de- and the highly skewed distribution of the scores,pressive symptomatology in a group of inpatients non-parametric statistical procedures were used. Forreferred for diagnosis and treatment of major depres- the calculation of correlations, Kendall’s tau test wassion. used, and for measurement of the differences be-

tween baseline and endpoint scores the WilcoxonSigned Rank test was used. To assess differencesbetween data from the study group and those from

2. Method the normative Dutch sample, Student’st-test wasused because of the large number of subjects that

The study was conducted on 40 non-bipolar were compared. As the criterion for treatment effect,depressive inpatients of whom five were excluded i.e. responders versus non-responders, a HDRS score

G. Marijnissen et al. / Journal of Affective Disorders 70 (2002) 219–223 221

of 16 was chosen in order to obtain reasonably As shown in Table 1, treatment with antidepres-comparable groups. sants resulted in a 43% decrease of depressive

symptomatology on both the HDRS and MADRS(Wilcoxon Signed Rank test; both scales:P ,

3. Results 0.001). However, scores on the TCI temperamentdimensions did not differ significantly from pretreat-

Pharmacological treatment of depression encom- ment values. A correlation of 0.38 (P 50.001) andpassed selective serotonin reuptake inhibitors (n 5 0.53 (P 5 0.004) was found at endpoint between the7), the MAO inhibitor tranylcypromine (n 5 1), HA value and the total scores on HDRS andnefazodone (n 5 1) and tricyclics (n 5 22); four MADRS, respectively.patients were treated with mood stabilizers. The In order to investigate the influence of depressiveinvestigators were not involved in the choice of symptomatology on personality dimensions, patientstreatment for any of the patients. with a baseline HDRS score of$16 (n 5 27) and a

The mean baseline scores on the HDRS and score at endpoint of,16 (n 5 19) were groupedMADRS as well as those on the seven personality according to an arbitrary response criterion of at leastfactors are presented in Table 1. As can be inferred a 40% reduction on the HDRS, yielding 17 re-from this table, scores on the personality dimensions sponders. Responders (n 517) and non-respondersharm avoidance (HA) and self-directedness (SD) (n 5 18) did not differ in their scores on the per-differ significantly from the normative data, in that sonality dimensions at baseline, in particular the HAHA is increased [t(432)57.6; P , 0.001] and SD is and SD values (data not shown). In addition, adecreased [t(432)5 5.9; P , 0.0001] in the de- comparison was made between patients showingpressed patients. No significant male–female differ- complete remission (HDRS,8; n 5 12) and thoseences emerged in this group of patients. As expected, with a HDRS endpoint score of$8 (n 5 23). Boththe total scores on baseline HDRS and MADRS were patients with complete remission (n 5 12) and thosecorrelated (0.65;P ,0.0001). However, no signifi- with remaining depressive symptoms (n 5 23) had acant correlation could be demonstrated between persistently higher score on the HA personalityseverity of depression and HA. dimension of 21.3 and 25.3, respectively.

Subsequent analysis revealed that the enhanced Finally, no difference could be demonstrated invalue for the personality dimension HA could not be TCI scores as a function of the number of previousattributed to a higher score on one of the four HA depressive episodes.subscales: worry /pessimism, fear of uncertainty,shyness and fatigability; they were uniformly higher.

4. Discussion

Table 1In the present study, the relationship betweenBaseline and endpoint scores (6S.D.) of depressive symp-

tomatology and personality dimensions (n 5 35) scores of personality dimensions and severity ofdepressive symptomatology as well as the effect ofBaseline Endpoint Dutch normative

data (n 5 399) pharmacological treatment on these dimensions wasinvestigated in 35 inpatients with a non-bipolarHDRS 20.866.9 11.867.6major depressive episode. The main findings are that

MADRS 25.869.8 14.7611.8depressed patients have a higher harm avoidance

TCI-NS 16.866.0 17.765.5 18.665.6 score and a lower self-directedness score as com-TCI-HA 24.366.7* 23.965.6 15.266.8 pared to a normative group and that TCI scores doTCI-RD 15.363.4 15.762.7 16.163.8

not predict response to treatment with antidepres-TCI-P 4.661.8 4.261.8 4.262.0sants. In addition, reduction of mood symptoms inTCI-SD 25.567.6* 27.667.8 32.666.8

TCI-C 31.265.5 31.965.6 33.565.8 the total group coincided only marginally withTCI-ST 13.466.6 11.365.9 12.166.3 changes in HA and SD scores.

* t-Test; P ,0.001. These results imply that TCI scores are not state

222 G. Marijnissen et al. / Journal of Affective Disorders 70 (2002) 219–223

after paroxetine treatment in volunteers with generalizeddependent but reflect a more enduring personalityanxiety disorder. Psychopharmacol. Bull. 34, 165–166.trait, in this case higher HA and lower SD, in

American Psychiatric Association, 1994. Diagnostic and Statisticalpatients with major depression. Comparable findingsManual of Mental Disorders, 4th Edition. American Psychiatric

´ ´have been published by Herran and Vazques-Bar- Association, Washington, DC.quero (1998) and Richter et al. (2000). Ampollini, P., Marchesi, C., Signifredi, R., Gianaglia, E., Scar-

The finding of an increased HA may, however, be dovi, F., Codeluppi, S., Maggini, C., 1999. Temperament andpersonality features in patients with major depression, panicnon-specific, in that such observations have beendisorder and mixed conditions. J. Affect. Disord. 52, 203–207.reported in patients suffering from various other

Battaglia, M., Przybeck, T.R., Bellodi, L., Cloninger, C.R., 1996.diagnostic entities such as obsessive compulsiveTemperament dimensions explain the comorbidity of psychiat-

disorder (Pfohl et al., 1990; Bogetto et al., 1997; ric disorders. Comp. Psychiatry 37, 292–298.Richter et al., 1996), anxiety disorders (Starcevic et Bogetto, F., Barzega, G., Bellino, S., Maina, G., Ravizza, L.,al., 1995, 1996; Mulder et al., 1994), eating disorders 1997. Obsessive-compulsive disorder and personality dimen-

sion: a study report. Eur. J. Psychiatry 11, 156–161.(Waller et al., 1993; Kleifield et al., 1994; Bulik etBrody, A.L., Saxena, S., Fairbanks, L.A., Alborzian, S., Demaree,al., 1995), premenstrual syndrome (Freeman et al.,

H.A., Maidment, K.M., Baxter, L.R., 2000. Personality1995), adult ADHD (Downey et al., 1997) and allchanges in adult subjects with major depressive disorders or

cluster C personality disorders (Battaglia et al., 1996; obsessive-compulsive disorder treated with paroxetine. J. Clin.Verhoeven et al., 1999). Psychiatry 61, 349–355.

From these extensive literature data it has become Brown, S.L., Svrakic, D.M., Przybeck, T.R., Cloninger, C.R.,1992. The relationship of personality to mood and anxietyclear that a personality trait such as high HA occursstates: a dimensional approach. J. Psychiatr. Res. 26, 197–211.across several diagnostic categories which are known

Bulik, C.M., Sullivan, P.F., Weltzin, T.E., Kaye, W.H., 1995.to be longitudinally dependent (Tyrer et al., 1997).Temperament in eating disorders. Int. J. Eat. Disord. 17,As far as it concerns the categorical entity of251–261.

depression, HA may nearly be identical to the older Chien, A.J., Dunner, D.L., 1996. The Tridimensional Personality´concept of neuroticism as was suggested by Herran Questionnaire in depression: state versus trait issues. J.

´ Psychiatr. Res. 30, 21–27.and Vazques-Barquero (1998).Cloninger, C.R., 1986. A unified biosocial theory of personalityIn conclusion, the results of the present study

and its role in the development of anxiety states. Psychiatr.demonstrate that the personality dimension HA is aDev. 3, 167–226.trait factor in depression which, however, is of no

Cloninger, C.R., 1987. A systematic method for clinical descrip-predictive value for antidepressant responsiveness. It tion and classification of personality variants. Arch. Gen.should be stressed, however, that the state versus Psychiatry 44, 573–588.trait issue is obscured by the influence of psycho- Cloninger, C.R., 1988. A unified biosocial theory of personality

and its role in the development of anxiety states: a reply topathology on selfconcepts and the circumstance thatcommentaries. Psychiatr. Dev. 2, 83–120.psychiatric symptoms change more rapidly than

Cloninger, C.R., 1994. Temperament and personality. Curr. Opin.selfconcepts. In addition, the instructions to theNeurobiol. 4, 266–273.

patients with respect to the completion of the TCI Cloninger, C.R., Svrakic, D.M., Przybeck, T.R., 1993. A psycho-might be of crucial importance, since the patient is biological model of temperament and character. Arch. Gen.free to choose between completing the questionnaire Psychiatry 50, 975–990.

Cloninger, C.R., Przybeck, T.R., Svrakic, D.M., Wetzel, R.D.,in accordance with his current state of mind or with1994. The Temperament and Character Inventory (TCI): ahabitual responding irrespective of the disease epi-guide to its development and use. Center for Psychobiology ofsode. Finally, psychotropics like SSRI’s have beenPersonality, Washington University, St. Louis, MI.

demonstrated to exert effects on personality charac- Downey, K.K., Stelson, F.W., Pomerleau, O.F., Giordani, B.,teristics independent of clinical treatment response 1997. Adult attention deficit hyperactivity disorder: psychologi-

cal test profiles in a clinical population. J. Nerv. Ment. Dis.(Brody et al., 2000).185, 32–38.

Duijsens, I.J., Goekoop, J.G., Spinhoven, P., Eurelings-Bontekoe,E.H.M., 1997. De temperament en karakter vragenlijst (TCI).

References NTvP 52, 199–202.Freeman, E.W., Schweizer, E., Rickels, K., 1995. Personality

Allgulander, C., Cloninger, C.R., Przybeck, T.R., Brandt, L., factors in women with premenstrual syndrome. Psychosom.1998. Changes on the temperament and character inventory Med. 57, 453–459.

G. Marijnissen et al. / Journal of Affective Disorders 70 (2002) 219–223 223

Hamilton, M., 1960. A rating scale for depression. J. Neurol. Pfohl, B., Black, D., Noyes, Jr. R., Kelly, M., Blum, N., 1990. ANeurosurg. Psychiatry 23, 56–62. test of the tridimensional personality theory: association with

Hamilton, M., 1967. Development of a rating scale for primary diagnosis and platelet imipramine binding in obsessive-com-depressive illness. Br. J. Soc. Clin. Psychol. 6, 278–296. pulsive disorder. Biol. Psychiatry 28, 41–46.

Hansenne, M., Pitchot, W., Gonzalez-Moreno, A., Machurot, P.Y., Richter, J., Eisemann, M., Richter, G., 2000. Temperament andAnsseau, M., 1998. The Tridimensional Personality Ques- character during the course of unipolar depression amongtionnaire (TPQ) and depression. Eur. Psychiatry 13, 101–103. inpatients. Eur. Arch. Psychiatry Clin. Neurosci. 250, 40–47.

Hansenne, M., Reggers, J., Pinto, E., Kjiri, K., Ajamier, A., Richter, M.A., Summerfeldt, L.J., Joffe, R.T., Swinson, R.P.,Ansseau, M., 1999. Temperament and character inventory 1996. The Tridimensional Personality Questionnaire in obses-(TCI) and depression. J. Psychiatr. Res. 33, 31–36. sive-compulsive disorder. Psychiatry Res. 65, 185–188.

Hellerstein, D.J., Kocsis, J.H., Chapman, D., Stewart, J.W., Snaith, R.P., 1993. What do depression rating scales measure? Br.Harrison, W., 2000. Double-blind comparison of sertraline, J. Psychiatry 163, 293–298.imipramine, and placebo in the treatment of dysthymia: effects Snaith, R.P., 1996. Present use of the Hamilton Depression Ratingon personality. Am. J. Psychiatry 157, 1436–1444. Scale: observations on method of assessment in research of

´ ´Herran, A., Vazques-Barquero, J.L., 1998. Personality dimensions, depressive disorders. Br. J. Psychiatry 168, 594–597.the TPQ, and depression. Eur. Psychiatry 13, 434. Starcevic, V., Uhlenhuth, E.H., Fallon, S., 1995. The Tridimen-

Joffe, R.T., Bagby, R.M., Levitt, A.J., Regan, J.J., Parker, J.D.A., sional Personality Questionnaire as an instrument for screening1993. The Tridimensional Personality Questionnaire in major personality disorders: use of patients with generalized anxietydepression. Am. J. Psychiatry 150, 959–960. disorder. J. Pers. Disord. 9, 247–253.

Joyce, P.R., Mulder, R.T., Cloninger, R.C., 1994. Temperament Starcevic, V., Uhlenhuth, E.H., Fallon, S., Pathak, D., 1996.predicts clomipramine and desipramine response in major Personality dimensions in panic disorder and generalizeddepression. J. Affect. Disord. 30, 35–46. anxiety disorder. J. Affect. Disord. 37, 75–79.

Kleifield, E.I., Sunday, S., Hurt, S., Halmi, K.A., 1994. The Strakowski, S.M., Faedda, G.L., Tohen, M., Goodwin, D.C., Stoll,Tridimensional Personality Questionnaire: an exploration of A.L., 1992. Possible affective-state dependence of the Tridi-personality traits in eating disorders. J. Psychiatr. Res. 28, mensional Personality Questionnaire in first-episode psychosis.413–423. Psychiatry Res. 41, 215–226.

Montgomery, S., Asberg, M., 1997. A new depression scale Strakowski, S.M., Dunayevich, E., Keck, P.E., McElroy, S.L.,designed to be sensitive to change. Br. J. Psychiatry 134, 1995. Affective state dependence of the Tridimensional Per-382–389. sonality Questionnaire. Psychiatry Res. 57, 209–214.

Mulder, R.T., Joyce, P.R., Cloninger, C.R., 1994. Temperament Svrakic, D.M., Przybeck, T.R., Cloninger, C.R., 1992. Moodand early environment influence comorbidity and personality states and personality traits. J. Affect. Disord. 24, 217–226.disorders in major depression. Comp. Psychiatry 35, 225–233. Tanaka, E., Sakamoto, S., Kijima, N., Kitamura, T., 1998.

Naito, M., Kijima, N., Kitamura, T., 2000. Temperament and Different personalities between depression and anxiety. J. Clin.Character Inventory (TCI) as predictors of depression among Psychol. 54, 1043–1051.Japanese college students. J. Clin. Psychol. 56, 1579–1585. Tyrer, P., Gunderson, J., Lyons, M., Tohen, M., 1997. Special

Nelsen, M.R., Dunner, D.L., 1995. Clinical and differential feature: extent of comorbidity between mental state anddiagnostic aspects of treatment-resistant depression. J. personality disorders. J. Pers. Disord. 11, 424–459.Psychiatr. Res. 29, 43–50. Verhoeven, W.M.A., Marijnissen, G., Van Ooy, J.M., Tuinier, S.,

Nelson, E.C., Cloninger, C.R., 1995. The Tridimensional Per- Van den Berg, Y.W.M.M., Pepplinkhuizen, L., Fekkes, D., 1999.sonality Questionnaire as a predictor of response to nefazodone Dysperceptions and serotonergic parameters in borderlinetreatment of depression. J. Affect. Disord. 35, 51–57. personality disorders: effects of treatment with risperidone.

Nelson, E., Cloninger, C.R., 1997. Exploring the TPQ as a New Trends Exp. Clin. Psychiatry 15, 9–16.possible predictor of antidepressant response to nefazodone in a Waller, D.A., Gullion, C.M., Petty, F., Hardy, B.W., Murdock,large multi-site study. J. Affect. Disord. 44, 197–200. M.V., Rush, A.J., 1993. Tridimensional Personality Ques-

Osher, Y., Cloninger, C.R., Belmaker, R.H., 1996. TPQ in tionnaire and serotonin in bulimia nervosa. Psychiatry Res. 48,euthymic manic-depressive patients. J. Psychiatr. Res. 30, 353– 9–15.357.