Mood Temperaments: A basic explanation
Temperament reflects the biological component of personality; it is about half genetic, and appears to be basically stable from childhood into later life. Mood temperaments can be conceived as basically mild versions of depressive or bipolar illness, with three major varieties:
Hyperthymia
Hyperthymia reflects mild constant manic symptoms. These people are energetic, active, workaholics, life-of-the-party, highly sociable, very funny, curious and even sometimes impulsive, sometimes risk-takers. They can be very charismatic, creative, and productive. Often they are successful professionally, wealthy, and well-known. They tend to need less sleep than the norm (ie, fine with 6 hours of sleep nightly or less), with a high level of energy.
Dysthymia and Cyclothymia
Dysthymia reflects mild constant depressive symptoms. These people are relatively low in energy, slow in acting and can be indecisive, shy, less sociable, and often thoughtful and introspective.
Cyclothymia reflects mild manic and depressive symptoms, alternating with each other on the order of days or less.
DSM definitions of the latter two definitions are not as I describe them here, and hyperthymia is not in DSM at all. DSM uses these terms as “disorders”, on a par with bipolar illness or schizophrenia. In fact, these conditions were always conceived as mild variations of the disease of manic depression, but not themselves as diseases. They are formes frustes of manic-depression, i.e., very mild manifestations, like borderline elevated glucose which is related to but different than the diagnosis of diabetes. Temperaments are extremes of personality traits that happen in families of persons with manic-depressive illness, or in those persons themselves in between their mood episodes.
Genetics
Mood temperaments are genetically related to recurrent depressive illness and bipolar illness, and thus can be thought of as reflecting what happens when someone gets some genes for those conditions, but not enough genes to cause the full-blown illness.
It is relevant that people can have full-blown bipolar illness or severe recurrent depression, and they can also have mood temperaments, in between their mood episodes. Thus, someone can have recurrent severe unipolar depressive episodes, with hyperthymic temperament in between those episodes as their “normal” baseline. Such persons are diagnosed with “MDD” by DSM methods, because DSM ignores the concept of mood temperament. Yet, that type of presentation clearly includes manic symptoms (though not episodes) as part of the clinical picture, and thus is part of the manic-depressive spectrum.
We have found that about 50% of persons with bipolar illness have mood temperaments, most commonly cyclothymia, but 50% do not have any mood temperaments, i.e., they are in the normal range of personality traits.
Diagnotic relevance
Mood temperaments can be important for diagnosis and treatment:
For diagnosis, having mood temperaments themselves can have benefits and harms. On the harm side, the symptoms are mild but constant. Over time, they can cause problems in life, like divorce or losing jobs or friends. These effects sometimes are not obviously related to the temperament, because they happen slowly over time. It is like Chinese water torture, with drips of water accumulating over time; in contrast, the mood episodes of full unipolar or bipolar depressive illness are like storms that come all of a sudden, inundate an area, and then go away. Both cases lead to suffering, one mildly but consistently, the other severely but rapidly.
Also, if mood temperaments are ignored, people may be misdiagnosed as having “MDD” because the manic symptoms they experience constantly are ignored since they are not severe episodes that come and go, but rather mild chronic aspects of hyperthymia or cyclothymia. By ignoring these constant manic symptoms, antidepressants are overused, with less efficacy and harmful consequences.
Treatment relevance
The treatment is low-dose mood stabilizers, like lithium 300-600 mg/d or divalproex 250-500 mg/d. These are about half the usual doses in bipolar illness. This advice is based on limited observational studies. Almost nothing else has been published. In the PL clinical experience, low dose dopamine blockers, such as aripiprazole 2-5 mg/d, also may be effective.
In short, the treatment is simple, but the diagnosis is difficult.
Besides the simplicity of using low-dose mood stabilizers, the other key to treatment is to stop doing everything else. In particular, stop or don’t use antidepressants. This perspective is based on PL clinical experience mostly. But a number of studies show that if someone has hyperthymia or cyclothymia as a mood temperament, he/she will be more likely to experience a manic episode with antidepressant treatment. Also, it is my view, though not yet well proven with studies, that antidepressants are less effective in such persons. This is often the case by means of the presence of “mixed depression”, depression mixed with manic symptoms (but not a full-blown manic episode). This kind of “mixed depression” is more common in persons who have hyperthymic or cyclothymic temperaments. Antidepressants seem less effective in mixed than pure depression, and antidepressants seem to worsen mixed depression, causing more agitation and even sometimes suicide. In contrast, dopamine blockers (neuroleptics) are effective in mixed depression, as we have shown in a randomized clinical trial with ziprasidone.
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