Temperament as a basic element in bipolar spectrum and in sub-threshold manifestations: a brief review of psychiatric literature

Il temperamento come elemento fondante dello spettro bipolare e delle manifestazioni sottosoglia: una breve rassegna della letteratura psichiatrica

D. Harnic*, A. Koukopoulos**, M. Mazza*, L. Janiri*, P. Bria*

* Istituto di Psichiatria e Psicologia, Ambulatorio per i Disturbi Bipolari, Università Cattolica del Sacro Cuore di Roma; ** Centro "Lucio Bini", Roma


The aim of this paper is to present a brief update on temperament, emphasizing its overarching importance in the field of mood disorders and stressing its role as one of the cornerstones of the bipolar spectrum. The hypothesis, first proposed by Kraepelin, that temperament can predispose to or be a risk factor for or serve as a substrate for the development of manifest psychopathology, has been confirmed by numerous contemporary clinical studies. Classical and recent literature, in addition to empirical, systematic and experimental studies, demonstrate that affective temperaments can be considered as effective tools in identifying vulnerability to mood disorders. In recent years, therefore, attention to temperament and the relationship between temperamental traits and different psychopathological frames has become an increasingly common topic for study and research.


Two independent investigators carried-out literature search (D. Harnic and M. Mazza). The following databases were screened: PubMed, BioMedCentral, ISI Web of Science, and PsycINFO. The keywords used are: bipolar disorder; spectrum; temperament; subthreshold symptoms. Inclusion criteria include all publications from 1950 to 2010, with particular attention to reviews. Only the most significant and comprehensive contributions were included in this study. The objective of this work is not to conduct a systematic review of literature but to provide a concise but comprehensive overview of the link between temperament and the bipolar spectrum.


In contrast to the dichotomous conception proposed by Kraepelin that, until relatively recent times, considered mania and depression as two distinct and separate categories, Akiskal has posited a psychopathological “continuum” between temperament and affective disorders (bipolar spectrum). In fact, reconstructing the history of patients with mood disorders, and especially in those with bipolar disorder, temperamental traits can already be observed in the premorbid period and continue to persist in symptom-free intervals. Mood disorders should be considered as belonging to a continuum in which “pure” depression and “pure” mania represent the extremes of a spectrum defined by three main psychopathological dimensions: affectivity, thought and volitionlocomotion. The “pure” manic and depressive poles occur when the three axes move simultaneously in the same direction, the rest are mixed affective states, described in detail by Wilhelm Weygandt, a pupil of Kraepelin. In 1999, Akiskal and Pinto have proposed a schematic classification of the different forms of the bipolar spectrum, advancing the existence of seven distinct categorical subtypes (Table I). In DSM-V this schematization should have replaced the current system of classification of bipolar disorders, but it has not been accepted by the task force on mood disorders. Some of the most experienced researchers and psychiatrists have studied in depth the above stated issues and have devised various instruments (the most relevant of which are described) that can help the clinician, in everyday practice, to identify even the most blurred dimensions of affective disorders. Tests, currently used both in the field of research and in the clinical field, were thus conceived in order to capture, in as much detail as possible, the protean expressions of the patients’ symptoms.


Affective disorders extend their dimensions beyond the expression of euphoria or depression alone, and appear to include, among others, conditions like anxiety, panic, irritability and emotional instability. In interpreting and diagnosing the varied expression of the bipolar spectrum, psychiatrists are today facing a major challenge in daily clinical practice. One of the main factors complicating this task is temperamental instability which often is the background of the attenuated bipolar spectrum. In recent years, attention to temperament and the relationship between temperamental traits and different psychopathological frames has become an increasingly frequent topic for study and research. Temperamental “dysregulation” is the pathological foundation of mood disorders and its alteration, in individuals, reflects a marked predisposition to develop a mood disorder. The need to clarify some aspects of this complex situation regarding temperament and subthreshold manifestations has disclosed the need to create new assessment tools that allow a refinement of the diagnostic process and, consequently, an individualization of psychopharmacotherapy.

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