a psychobiological approach to personality: examination within anxious outpatients

A psychobiological approach to personality: examination withinanxious outpatients

Susan Ball*, James Smolin, Anantha Shekhar

550 N. University Boulevard, Suite 3124, Indianapolis, IN 46202, USA

Received 8 February 2001; received in revised form 14 July 2001; accepted 2 November 2001

Abstract

Objective: To examine Cloninger’s psychobiological personality model among different anxiety and depressive outpatients as well

as normal healthy comparisons. In addition, the relationship between the underlying temperament dimensions and behavioralcoping strategies was also studied using the tri-axial model of coping. Methods: Subjects were 120 outpatients presenting to ananxiety disorders specialty clinic and 17 normal comparisons. They underwent a semi-structured clinical interview and completed abattery of questionnaires, including the Temperament and Character Inventory and the Strategic Approach to Coping Scale.

Results: On the temperament dimensions, the patients were elevated on the harm avoidance scale relative to the normal compar-isons; the temperament substrate was not differentiated by the anxiety or affective diagnostic types nor was there differencesbetween groups on the other temperament dimensions. Both severity of illness and the presence of a comorbid depressive disorder

each contributed independently to harm avoidance scores. Hypotheses regarding the association between underlying temperamentand behavioral coping strategies were supported for the dimensions of reward dependence and harm avoidance, but not for noveltyseeking. Conclusions: Cloninger’s psychobiological model is supported with the temperament of harm avoidance being the relevant

dimension for anxiety and affective disorders. The underlying temperament structure also has clinical relevance for the type ofcoping strategies that are utilized by an individual. # 2002 Elsevier Science Ltd. All rights reserved.

The substrate of personality and the development ofpsychopathology have been areas of intense investiga-tion. Competing models attempt to define and charac-terize the basic dimensions of human personalitydevelopment that allow for the expression of normalbehavior as well as both affective and behavioral dysregu-lation. In Cloninger et al.’s (1993) model, personalitydevelopment integrates biopsychosocial factors that aremanifested through temperament and character dimen-sions. Temperament represents automatic responses ininformation processing and learning, presumed to beheritable, whereas character reflects personality devel-opment in the context of insight learning and environ-mental experiences. Basic temperament dimensions arenovelty seeking, harm avoidance, reward dependence,and persistence. Each dimension is proposed to bemodulated by a different primary neurotransmitter.Psychopathology is then associated with dysregulation

among these systems reflective of the type of the dis-order.Among the temperament dimensions, novelty seeking

describes the initiation of behaviors, such as exploratoryand impulsivity, and is putated to be regulated by thedopamine system. The maintenance and continuation ofongoing behaviors, such as social attachment anddependence, is captured by reward dependence, which ismodulated by norepinephrine. Harm avoidance refersto the bias in the inhibition or cessation of behaviors,such as fatigability and anticipation of harm, and isassociated with the serotonin system (Pierson et al.,1999). Cloninger and colleagues’ validity studies havealso demonstrated a fourth dimension of personalityreferred to as persistence that was initially considered asubsystem of reward dependence, but has been demon-strated to be a separate dimension that shows geneticheritability, especially among women (Stallings et al.,1996).Upon this foundation of basic temperament, Clo-

ninger’s theory accounts for character developmentthough the organization of experience and relationships

0022-3956/02/$ - see front matter # 2002 Elsevier Science Ltd. All rights reserved.

PI I : S0022-3956(01 )00054-1

Journal of Psychiatric Research 36 (2002) 97–103

www.elsevier.com/locate/jpsychires

* Corresponding author. Tel.: +1-317-274-7422; fax: +1-317-274-

1497.

E-mail address: [email protected] (S. Ball).

with others. Three dimensions of character developmentrefer to the experience of the self as an autonomousindividual (self-directedness), the self as part of human-ity or society (cooperativeness), and the self as part ofthe universe (self-transcendence). Personality pathologyas characterized by the DSM Axis II diagnosis typicallyreflects low levels of both self-directedness and co-operativeness (Svarakic et al., 1993).Cloninger’s model has been assessed using the Tem-

perament and Character Inventory, which is a 226-itemquestionnaire that has been designed to measure thefour temperament and three character dimensions. Eachdimension, with the exception of persistence, has theo-retically derived subscales reflecting aspects of the pri-mary dimension. For example, harm avoidance ismeasured by four subscales: anticipatory worry, fear ofuncertainty, shyness, and fatigability. Similarly, rewarddependence has the subscales of sentimentality, attach-ment, and dependence. In the initial validation study,Svrakic et al. (1993) administered the TCI to 136 out-patients whose diagnosis was primarily a mood disorder(82%), with 48% also meeting criteria for a comorbidpersonality disorder.Subsequent validity studies of the TCI have included

populations of healthy controls and patients with dif-ferent disorders. Patients with panic disorder and general-ized anxiety disorder have demonstrated temperamentpatterns characterized by high harm avoidance that oftenremains elevated even after treatment (Saviotti et al.,1991; Starcevic et al, 1996). Among patients withobsessive–compulsive disorder, harm avoidance scoreswere elevated, but there were mixed findings for thedimensions of novelty seeking and reward dependence(Pfolhl et al., 1990; Richter et al., 2001). Chatterjee et al.(1997) compared 20 social phobics to normal controlsand found that social anxiety was characterized by ele-vations in harm avoidance and low novelty seeking aswell as low co-cooperativeness and self-directedness.Ampollini et al. (1999) found that patients with comor-bid panic and depression had higher elevations in harmavoidance than those with either disorder alone.An important aspect of whether the psychobiological

substrate influences personality is how it translates intospecific behaviors, in particularly behavioral responsesto mood states. Using a bioevolutionary perspective, thetri-axial model of coping conceptualizes that copingbehavior responds to potential stressors of loss ofresources, such as loss of objects (e.g. home), conditions(e.g. good marriage), personal (e.g. self-esteem), andenergy (e.g. money) that result in affective disturbance(Hobfoll et al., 1995). In order to adapt to these poten-tial losses and restore affective equilibrium, individualsengage in compensation behaviors that vary along thethree dimensions of activity, social ability, and direct-ness (Dunahoo, 1997). Different preferences along thesedimensions result in various coping strategies, such as

avoidance, social joining, or aggressive action. Com-paring the temperament and coping dimensions, it ishypothesized that novelty seeking will be associatedwith activity coping strategies, reward dependence withsociability coping strategies, and harm avoidance withdirectness coping strategies.The objective of the present study was to examine the

temperament and character profile among differenttypes of anxiety disorders in a specialty clinic setting. Asecond aim was to examine whether these differences intemperament and character were associated with self-reported behavioral differences among patients, in par-ticular their coping styles.

1. Method

1.1. Subjects

Subjects were 88 women and 49 men who were eval-uated through the Indiana University Anxiety DisordersClinic. This sample comprised 120 patients who werereferred to the clinic through a variety of sources,including self-referral, other physicians, insurance, andadvertisements, and 17 normal comparison subjectsrecruited from the university setting (12 women, fivemen). In order to be included in this study, patients hadto meet DSM-IV criteria for panic disorder, generalizedanxiety disorder, obsessive–compulsive disorder, socialphobia, specific phobia, or an affective disorder (majordepression or dysthymia). The normal comparisongroup had to demonstrate no current DSM-IV Axis Idisorders and no history of psychiatric treatment.

1.2. Assessment procedures

Participants were interviewed when they presented fortreatment at the center. As part of the intake pro-cedures, the patients gave written informed consent thattheir clinical information could be used for researchpurposes. All study and data collection procedures werereviewed and approved by the Indiana University—PurdueUniversity Indianapolis Institutional ReviewBoard.Subjects were interviewed by a clinical psychologist(n=76), psychiatric social worker (n=20), psychologyintern (n=13), psychiatry resident (n=21), or psychia-trist (n=6), who were each experienced in the assess-ment of anxiety disorders using a modified form of theAnxiety Disorders Interview Schedule for DSM-IV(DiNardo et al., 1994). The modification included focuson current diagnostic status rather than past history.Interviewers assessed the diagnostic criteria for eachanxiety and affective disorders and also inquired aboutprimary symptoms for psychotic, substance abuse, eat-ing disorders, and somatoform disorders. Subjects withsubstance abuse or psychotic symptoms were not inclu-

98 S. Ball et al. / Journal of Psychiatric Research 36 (2002) 97–103

ded in the sample. Cases were also reviewed at teammeetings for diagnostic clarification. The normal com-parisons were recruited from university and medicalsettings and completed the study procedures as part oftheir participation for an auxiliary study.Following their interview, subjects were given a

packet that included the Temperament and CharacterInventory (Cloninger et al., 1994). This questionnaireconsists of 226 items rated as true or false and scored bycomputer. For each temperament and character dimen-sion, a proportion score was calculated from the num-ber of items endorsed out of the total number of itemsfor that dimension. Symptom severity of anxiety anddepression were measured using the Beck Anxiety andBeck Depression Inventories (Beck et al., 1967, 1988)and the State-Trait Anxiety Inventory (Spielberger,1983). Subjects also completed the Anxiety SensitivityIndex (Peterson and Reiss, 1992), which is a 16-itemquestionnaire that assesses the psychological trait ofsensitivity to anxiety symptoms.Personality disorder symptoms were assessed by the

Personality Disorders Questionnaire-Revised, (PDQ-R;Hyler et al., 1992), which consists of items representingindividual criteria for each personality disorder thatsubjects endorse as ‘‘true’’ or ‘‘false’’. In addition to atotal score, items were grouped into Cluster A, ClusterB, and Cluster C personality disorders, and clusterscores were calculated as the proportion of itemsendorsed within each group. Coping styles were assessedby the Strategic Approach to Coping Scale (SACS;Hobfoll et al., 1994). The SACS responses were thenanalyzed into an average for each coping subscale, with1=‘‘not at all’’ and 5=‘‘extremely likely’’. The ninecoping subscales are assertive action, cautious action,seeking social support, social joining, instinctive action,avoidance, indirect action, antisocial action, andaggressive action. Subjects also completed an estimateof how impaired they felt in their work, family rela-tionships, leisure time, home management, and sociallife. For each area, they rated their perceived impair-ment on a 1–8 scale, where 1=‘‘not at all’’ and8=‘‘extremely’’. The five ratings were then averaged foran overall severity index. Questionnaire packets werereturned within 1–2 weeks from the interview.

2. Results

2.1. Patient demographics

The mean age for the entire sample was 36.2 years(S.D.=11.4) with the women being significantlyyounger than the men (M=34.3 yrs, S.D.=10.6 vs.M=39.4, S.D.=12.2, P=0.01). Seventy-eight percentof subjects were employed outside of the home. Forty-eight percent were married, 15% divorced, and 35%

single. Fifty-three percent (n=64) of the patients wereon medications at the time of the evaluation. Of thoseon medications, 18 were taking anti-anxiety medicationonly (benzodiazepines, Buspar), 21 were taking anti-depressant medications (tricyclics, SSRIs), and 25 weretaking both an antidepressant and anti-anxiety medica-tion.Among the 120 subjects diagnosed with an Axis I

disorder, 37.5% were diagnosed with a primary panicdisorder, 14% with generalized anxiety disorder, 11%with social phobia, 10% with obsessive–compulsive dis-order, 17.5% with a primary depressive disorder, and10% were grouped as Other Anxiety (primary specificphobia or anxiety disorder not otherwise specified).Table 1 displays the scores of each group on the anxietyand depressive scales, indicating consistency betweendiagnostic status and self-report ratings. Forty-one per-cent of the patients did not have any comorbid psy-chiatric conditions, 26% had a comorbid anxietydiagnosis, and 33% met criteria for both an anxietydisorder and a depressive disorder. Diagnostic subtypewas not associated with particular raters [� 2 (24)=19.5,ns] nor was the number of diagnoses assigned based onrater [F (4,117)=0.82, ns]. Patients who were takingpsychotropic medications had significantly greater harmavoidance than those who were not taking medications(t=2.32, P<0.05), but did not differ on the other tem-perament or character dimensions. Harm avoidancescores did not differ based on the type of psychotropicmedication [F (4,117) =1.35, ns].

2.2. Temperament and character profiles

To examine differences among groups, a MANOVAwas computed on the TCI scale scores with Diagnosticgroup as the between subjects variables. Among thetemperament scales, diagnostic type was only significantfor the harm avoidance (HA) scale, F (6,130)=11.07,P<0.001. Means for each group on the TCI scales aredisplayed in Table 2. Tukey post-hoc tests showed nor-mal controls were significantly lower on HA than allother groups except for the Other Anxiety group,P<0.001. The Other Anxiety group were also sig-nificantly lower than the generalized anxiety disorderand depression groups on the HA scale, P<0.01. Therewere no differences between the other diagnostic groupson any of the other temperament scales.With regard to the character scales of self-directed-

ness, cooperativeness, and self-transcendence, diag-nostic type was a significant effect for self-directedness[F (6,130)=7.14, P<0.001] and for cooperativeness [F(6, 130)=3.27, P<0.001], but not for self-transcen-dence. Tukey post-hoc tests showed that the normalcontrols scored significantly higher on self-directednessthan the other groups, except for the Other Anxietygroup, P<0.001. The other groups did not differ among

S. Ball et al. / Journal of Psychiatric Research 36 (2002) 97–103 99

each other, with the exception that the Other Anxietygroup demonstrated significantly higher self-directed-ness scores compared to the OCD group, P<0.05. Forcooperativeness, patients with OCD had significantlylower scores than the normal comparison group,P<0.01, and the Other Anxiety group, P<0.05.The temperament dimension of harm avoidance was

also associated with the self-report scores using a linearregression analysis. The state measures (BDI, BAI, andSTAI-State) were entered as a block followed by thetrait measures (STAI-Trait, ASI scores). With bothblocks in the analysis, higher harm avoidance scoreswere predicted by higher STAI-Trait scores (t=5.27,P<0.01) and ASI scores (t=3.61, P<0.001; overallR=0.76, P<0.001). The self-report measures howeverwere not significant predictors of novelty seeking(R=0.11, ns), reward dependence (R=0.24, ns) or per-sistence (R=0.21, ns). Among the character dimensions,low self-directiveness was predicted by the state mea-sures (R=0.67, P<0.001) and increased in predictionwith the addition of the trait block (R=0.85, P<0.001,increase in R2=27%). Similarly, cooperativeness wasalso associated significantly with both state (R=0.37,P<0.01) and the addition of the trait block (R=0.51,P<0.001, increase in R2=12%), with STAI-Trait scoreshaving the greatest beta weight (B=�0.61). Using thesame analysis, state measures as a block were sig-nificantly predictive of self-transcendence (R=0.33,P<0.05, with Beck Anxiety Scale scores having the

greatest beta weight (B=0.28), but the trait measuresdid not significantly increase prediction (R=0.35,increase in R2=2%).

2.3. Effects of comorbidity

For these analyses, the normal control group wasexcluded. Patients were classified as having only theirprimary disorder, a comorbid anxiety disorder, ormeeting criteria for both anxiety and depression, eitherprimary or secondary. Mean scores on the TCI for thesegroups are shown in Table 3. A MANOVA was calcu-lated using the TCI scales as the dependent variablesand comorbidity status as the between subjects variable.Comorbidity demonstrated a significant effect for theHarm Avoidance scale [F (2, 117)=13.91, P<0.001]and the Self-directedness scale [F (2, 117)=11.57,P<0.001]. Tukey post-hoc tests demonstrated thatthose patients with depression scored significantlyhigher on the HA scale and significantly lower on theSDR scale than both the no comorbid or anxietycomorbid groups, P<0.001.In order to separate severity effects from the presence

of depression, a stepwise multiple regression analyseswas conducted on the HA scores, with severity indexentered first and then comorbidity status. Both severityof illness (t=3.79, P<0.001) and presence of comorbiddepression (t=3.4, P<0.001) contributed independentlyto predicting HA scores, R=0.53, P<0.001. Similarly

Table 1

Mean and S.D. of scores for anxiety and depression scales in 120 psychiatric outpatients and 17 controlsa

Diagnosis ASI (S.D.) BAI (S.D.) BDI (S.D.) STAI-S (S.D.) STAI-T (S.D.)

None (n=17) 9.35 (6.58) 1.59 (2.12) 1.29 (2.20) 24.76 (5.20) 27.47 (6.87)

Panic Disorder (n=45) 31.88 (11.86) 25.91 (12.05) 19.80 (12.60) 44.79 (14.44) 50.67 (10.80)

GAD (n=17) 27.80 (7.84) 17.31 (8.49) 16.88 (9.14) 44.20 (12.70) 51.75 (10.29)

Social Phobia (n=13) 26.82 (12.110 15.92 (12.32) 13.15 (9.43) 42.31 (11.69) 47.83 (12.44)

OCD (n=12) 31.09 (12.71) 16.58 (10.70) 18.42 (11.60) 47.73 (11.05) 57.91 (10.43)

Other Anxiety (n= 12) 21.09 (13.73) 10.92 (15.23) 10.50 (13.23) 36.73 (12.97) 43.91 (14.33)

Depression (n=21) 32.33 (16.06) 18.81 (14.03) 26.57 (13.55) 57.68 (11.40) 60.32 (8.71)

a BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; STAI-S, State Trait Anxiety Inventory State score; STAI-T State Trait Anxiety

Inventory Trait Score; GAD, generalized anxiety disorder; OCD, obsessive–compulsive disorder.

Table 2

Mean proportion scores and S.D. for temperament and character scales in 120 psychiatric outpatients and 17 controlsa

Diagnosis NS (S.D.) HA (S.D.) RD (S.D.) P (S.D.) SDR (S.D.) COOP (S.D.) STR (S.D.)

None (n=17) 0.47 (0.12) 0.29 (0.13) 0.73 (0.09) 0.70 (0.22) 0.90 (0.08) 0.92 (0.08) 0.33 (0.17)

Panic Disorder (n=45) 0.45 (0.14) 0.64 (0.21) 0.68 (0.18) 0.60 (0.27) 0.67 (0.19) 0.83 (0.12) 0.38 (0.14)

GAD (n=17) 0.40 (0.14) 0.73 (0.16) 0.72 (0.15) 0.79 (0.27) 0.65 (0.17) 0.83 (0.09) 0.32 (0.16)

Social Phobia (n=13) 0.49 (0.18) 0.64 (0.22) 0.69 (0.11) 0.60 (0.34) 0.65 (0.17) 0.81 (0.14) 0.35 (0.11)

OCD (n=12) 0.45 (0.16) 0.65 (0.16) 0.63 (0.20) 0.70 (0.25) 0.54 (0.24) 0.74 (0.19) 0.39 (0.14)

Other Anxiety (n=12) 0.45 (0.16) 0.43(0.22) 0.67 (0.18) 0.73 (0.22) 0.78 (0.19) 0.89 (0.04) 0.36 (0.12)

Depression (n=21) 0.49 (0.13) 0.68 (0.22) 0.62 (0.14) 0.66 (0.19) 0.60 (0.17) 0.81 (0.12) 0.39 (0.18)

a TCI temperament dimensions: NS, novelty seeking; HA, harm avoidance; RD, reward dependence; P, persistence; SDR, self-directedness;

COOP, cooperativeness, STR, self-transcendence. Diagnosis: GAD, generalized anxiety disorder; OCD, obsessive–compulsive disorder.


for SDR scores, both severity (t=�3.37, P<0.001) andcomorbidity status (t=�2.9, P<0.001) were significantpredictors of self-directedness, R=0.48, P<0.001.

2.4. Correlates with personality disorders

To examine the relationship between temperamentand character dimensions and personality disorders,zero order correlations were calculated between each ofthe TCI scales and the PDQ-R Cluster scores as well asthe total PDQ-R scores (Table 4). Given the strongassociations with the character dimensions, partial cor-relations were then calculated to examine the relation-ship between the cluster scores and temperamentdimensions while controlling for the self-directednessand cooperativeness scores. The pattern emerged inwhich Cluster A was associated with low rewarddependence (r=�0.33, P<0.001) high harm avoidance(r=0.18, P<0.05), and greater persistence (r=0.28,P<0.01); Cluster B was significantly associated withonly higher novelty seeking (r=0.28, P<0.01); andCluster C was correlated with high harm avoidance(r=0.39, P<0.001), low novelty seeking (r=�0.25,P<0.01), and persistence (r=0.23, P<0.01).

2.5. Correlates with coping styles

Using the entire sample, scores on the TCI were cor-related with the Strategic Approach to Coping Scales as

shown in Table 5. Subjects who scored high on harmavoidance were more likely to report coping withstressful situations using avoidance and were lesslikely to use assertive (P<0.001) or aggressive action(P<0.001). Novelty seeking tended to be unrelated todifferent coping strategies whereas reward dependencewas associated positively with social support and socialjoining. Persistence was positively associated withassertiveness (P<0.001) and was negatively related toavoidance (P<0.01).Similarly, character scales were also associated with

different coping styles. Those subjects who scoredhigher on the self-directedness scale were more likely toreport using assertive and cautious action, but notavoidance behaviors. Those who were more likely to becooperative reported using more prosocial copingmethods, such as social support and social joining, andwere less likely to use antisocial, aggressive, or indirectaction. Self-transcendence as a character trait was asso-ciated only with the tendency to rely on coping skillscharacterized as instinctive action (P<0.001).

3. Discussion

The results from the present study support that anxi-ety and depressive disorders are primarily associatedwith the temperament dimension of harm avoidance.This finding is consistent with previous research that has

Table 3

Mean proportion scores and S.D. for TCI scales in 120 psychiatric outpatients by the presence of comorbid anxiety and affective disorders

TCI Scale No comorbid

Diagnosis (n=59)

(S.D.)

Comorbid Anxiety

Disorder (n=31)

(S.D.)

Anxiety and Depression

(n=40) (S.D.)

Novelty Seeking 0.46 (0.17) 0.44 (0.14) 0.46 (0.13)

Harm Avoidance 0.55 (0.23) 0.62 (0.18) 0.77 (0.15) ***

Reward Dependence 0.69 (0.16) 0.69 (0.17) 0.64 (0.16)

Persistence 0.64 (0.30) 0.68 (0.25) 0.66 (0.24)

Self-Directedness 0.71 (0.18) 0.70 (0.17) 0.54 (0.18) ***

Cooperativeness 0.84 (0.11) 0.83 (0.12) 0.79 (0.15)

***P<0.001.

Table 4

Correlations between TCI scores and personality disorder questionnaire self-report axis II cluster scores

TCI Scale Cluster A Cluster B Cluster C Total PDQ-R

scores

Novelty Seeking 0.04 0.36** �0.06 0.18*

Harm Avoidance 0.55 *** 0.47 ** 0.70** 0.65***

Reward Dependence �0.36*** �0.16 �0.07 �0.22*

Persistence 0.12 �0.06 0.09 0.03

Self-Directiveness �0.67*** �0.77*** �0.70*** �0.82***

Cooperativeness �0.47** �0.58*** �0.31** �0.52***

Self-Transcendence 0.14 0.14 0.10 0.16

*P<0.05. **P<0.01. ***P<0.001.


consistently found that harm avoidance is associatedwith affective dysregulation (e.g. Hansenne et al., 1999)However, previous studies have also indicated mixedfindings with regard to specific disorders and the othertemperament dimensions of novelty seeking, rewarddependence, and persistence. In this study, it was possi-ble to examine different groups simultaneously from thesame setting. The lack of difference between groups forthese other dimensions suggests that they are less dys-regulated within anxiety or anxious-depressive popula-tions.Interestingly, our study also supported previous find-

ings that the presence of comorbidity is associated withelevations in harm avoidance (Ampollini et al., 1999).However, we found that this increase was only asso-ciated with the additional comorbidity of a depressivediagnosis rather than solely due to having a secondarydiagnosis of an anxiety disorder. Anxiety comorbidity isthe rule rather than the exception and reflects the natureof the DSM-IV diagnostic system in which the disordersare determined based on the content of what a person isafraid of rather than solely on anxiety symptoms. Asindividuals are often afraid of more than one domain offear, then they typically meet criteria for more than onedisorder. From these findings, however, it suggest that atleast with regard to temperament, ‘‘anxiety is anxiety’’and that the underlying structure from one to two dis-orders remain the same. On the other hand, the additionof a depressive diagnosis indicates a separate risk forgreater harm avoidance that can not simply be accoun-ted as due to increasing severity of illness. Depressioncomorbidity results in a quantitative difference in theunderlying temperament structure. Anxiety and depres-sion have been shown to demonstrate common geneticinfluences (e.g. Kendler, 1996); thus, the dimension ofharm avoidance may be the shared expression of thisgenetic vulnerability for ‘‘internalizing’’ disorders.With regard to personality disorders, as shown in

previous research, the character dimensions were

strongly associated with Axis II pathology. Nonetheless,after controlling for these character influences, specificpersonality disorder clusters were associated with tem-perament dimensions indicative of the primary beha-vioral dysregulation. For example, Cluster Apersonality disorder traits, characterized by social alie-nation, were associated with both high harm avoidance,but low reward dependence. Avoidant personality traitson the other hand, also characterized by social anxietyand isolation, were more associated with low noveltyseeking rather than low reward dependence. Thus,although both types of these personality disorder clus-ters involve social avoidance, they can be differentiatedby the underlying temperament of reward dependence.Other influences on Axis II pathology scores were thestate and trait measures, with depression and traitanxiety both being significantly associated with thecluster scores. Axis II pathology may be an expressionof character development, but it is also clearly influ-enced by basic temperament interacting with currentsymptoms and distress levels.The clinical relevance of temperament and character

dimensions was demonstrated by their associations withbehavioral coping styles. We found partial support forthe hypothesis that the different dimensions would beassociated with specific types of coping strategies. Asexpected, harm avoidance was associated with the cop-ing dimension of directness, with positive associationswith avoidance and inverse relationship with directactions, such as assertiveness. Similarly, reward depen-dence was associated with socialability, particularlyseeking social support and social joining. Persistencewas also associated with prosocial strategies such asassertiveness. On the other hand, contrary to thehypothesis, novelty seeking was not strongly associatedwith the coping dimension of activity. The lack of sup-port for the hypothesized relationship may be due toconsideration of novelty seeking as being predominatedby sensation seeking rather than simply initiation of

Table 5

Correlations among temperament and character scales and the strategic approach to coping scales in 120 psychiatric outpatients and 17 normal

controls (n=137)a

TCI Scale ASR ACT SOC SUP SOC JOIN CAU ACT INST ACT IND ACT AVOID ANTISOC ACT AGG ACT

NS 0.04 0.11 0.06 �0.20* 0.10 0.15 �0.07 0.19* 0.21*

HA �0.46** �0.15 �0.15 �0.27* �0.06 �0.06 0.40** �0.19* �0.37**

RD 0.09 0.53** 0.48** �0.03 �0.08 �0.10 �0.14 �0.28* �0.23**

P 0.40** �0.10 0.12 0.07 0.12 �0.01 �0.36** 0.01 0.23**

SDR 0.47** 0.14 0.15 0.35** �0.04 �0.16 �0.41** �0.04 0.19*

COOP 0.25** 0.29** 0.34** 0.09 �0.15 �0.26** �0.22** �0.39** �0.19*

STR 0.10 0.02 0.14 0.00 0.31** 0.14 0.05 �0.05 0.00

a Strategic approach to coping scales: ASR, assertive action; SOC SUP, social support; SOC JOIN, social joining; CAU ACT, cautious action;

INST ACT, instinctive action; IND ACT, indirect action; AVOID, avoidance; ANTI SOC ACT, antisocial action; AGG ACT, aggressive action.

TCI Scales: NS, novelty seeking; HA, harm avoidance; RD, reward dependence; P, persistence; SDR, self-directedness; COOP, cooperativeness;

STR, self-transcendence.

*P<0.05. **P<0.01.


behaviors. The tendency to take action was actuallymore strongly related to the character dimension of self-directedness rather than the underlying temperamentstructure.One limitation of this study is that our independent

variable is the subjects’ diagnoses, and we did not con-duct inter-rater reliability. However, each interviewerwas trained with a senior interviewer in the use of thesemi-structured clinical interview, ADIS-IV, which hasshown good reliability. Further, the mean scores of thesubjects on the self-report questionnaires (Table 1) showthe profiles on these measures that have been found forthese diagnostic types in other studies. Finally, thediagnostic type and number of diagnoses were notassociated with particular raters.In summary, Cloninger’s psychobiological model

indicates that a primary dimension underlying anxietyand affective disorders is elevations in harm avoidance.Although the cross-sectional nature of this study pre-cludes determination of a causal relationship, there doesappear to be a quantitative relationship between theanxiety and affective disorders along this continuum.The clinical relevance of temperament dimensions isalso evidenced by their associations with behavioralcoping styles, with elevations of harm avoidance asso-ciated with indirect methods of coping, particularlyavoidance behaviors.

Acknowledgements

We would like to acknowledge that portions of thisstudy was supported by PHS grant MH55307-02 awar-ded to the first author.

References

Ampollini P, Marchesi C, Signifredi R, Ghinaglia E, Scardovi F,

Codeluppi S, Maggini C. Temperament and personality features in

patients with major depression, panic disorder, and mixed condi-

tions. Journal of Affective Disorders 1999;52:203–7.

Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring

clinical anxiety: psychometric properties. Journal of Consulting and

Clinical Psychology 1988:893–7.

Beck AT,Ward CH,MendelsonM,Mock J, Erbaugh J. An inventory for

measuring depression. Archives of General Psychiatry 1967:561–71.

Chatterjee S, Sunitha TA, Velayudhan A, Khanna S. An investigation

into the psychobiology of social phobia: personality domains and ser-

otonergic function. Acta Psychiatrica Scandinavica 1997;95:554–60.

Cloninger CR, Przybeck TR, Svrakic DM, Wetzet RD. The tempera-

ment and character inventory (TCI): a guide to its development and

use. 1994. Washington University, St, Louis (MO): Center for Psy-

chobiology of Personality, 1994.

Cloninger CR, Svarakic R, Dragan M, Przybeck TR. A psychobiolo-

gical model of temperament and character. Archives of General

Psychiatry 1993;50:975–90.

DiNardo P, Brown TA, Barlow D. The anxiety disorders interview

schedule for DSM-IV. New York: Psychological Corporation,

1994.

Dunahoo CL. The tri-axial model of coping: theory and instrument

development. Dissertation Abstracts International 57(9-B) 1997.

Hansenne M, Reggers J. Pinto Emmanuel, Kjiri K, Ajamier A,

Ansseau M. Temperament and character inventory (TCI) and

depression Journal of Psychiatric Research 1999;33:31–6.

Hobfoll SE, Dunahoo CA, Monnier J. Conversation of resources and

traumatic stress. In: Freddy JR, Hobfoll SE, editors. Traumatic

stress: from theory to practice. New York and London: Plenum

Press, 1995. p. 29–48.

Hobfoll SE, Dunahoo CL, Ben-Porath Y, Monnier J. Gender and

coping: the dual axis model of coping. American Journal of Com-

munity Psychology 1994;22:49–82.

Hyler SE, Skodol AE, Oldham JM, Kellman HD. Validity of the

Personality Disorders Questionnaire—revised. Comprehensive Psy-

chiatry 1992;33(2):73–7.

Kendler KS. Major depression and generalized anxiety disorder: same

genes (partly) different environments—revisited. British Journal of

Psychiatry 1996;168(Suppl 30):68–75.

Peterson RA, Reiss S. Anxiety Sensitivity Index Revised Test Manual.

Worthington, Ohio: International Diagnostic Services, Inc., 1992.

Pfolhl B, Black D, Noyes R, Kelley M, Blum N. A test of the tridi-

mensional personality theory: association with diagnosis and plate-

let imipramine binding in obsessive-compulsive disorder. Biological

Psychiatry 1990;28:35–40.

Pierson AR, Heuchert JW, Thomala L, Berk M, Plein H, Cloninger

CR. Relationship between serotonin and the temperament and

character inventory. Psychiatry Research 1999;89:29–37.

Richter MA, Summerfeldt LJ, Joffe RT, Swinson RP. The tridimen-

sional personality questionnaire in obsessive-compulsive disorder.

Psychiatry Research 2001;65:185–8.

Saviotti FM, Grandi S, Savron G, Ermentini R, Bartolucci G, Conti

S, Fava G. Characterlogical traits of recovered patients with panic

disorder and agoraphobia. Journal of Affective Disorders 1991;23:

113–7.

Spielberger CD. Manual for the State-Trait Anxiety Inventory. Palo

Alto (CA): Consulting Psychologists Press, 1983.

Stallings MC, Hewitt JK, Cloninger RC, Heath AC, Eaves LJ.

Genetic and environmental structure of the tridimensional person-

ality questionnaire: three or four temperament dimensions. Journal

of Personality and Social Psychology 1996;70:127–40.

Starcevic V, Uhlenhuth EH, Fallon S, Pathak D. Personality dimen-

sions in panic disorder and generalized anxiety disorder. Journal of

Affective Disorders 1996:75–9.

Svarakic DM, Whitehead C, Przybeck TR, Cloninger CR. Differential

diagnosis of personality disorders by the seven-factor model of

temperament and character. Archives of General Psychiatry 1993;

50:991–9.


a psychobiological approach to personality: examination within anxious outpatients

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