Neuropsychiatric Disease and Treatment
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The differences in temperament–character traits,
suicide attempts, impulsivity, and functionality
levels of patients with bipolar disorder I and II
Filiz Izci, Ebru Kanmaz Fındıklı, Serkan Zincir, Selma Bozkurt Zincir & Merve
Iris Koc
To cite this article: Filiz Izci, Ebru Kanmaz Fındıklı, Serkan Zincir, Selma Bozkurt Zincir & Merve
Iris Koc (2016) The differences in temperament–character traits, suicide attempts, impulsivity,
and functionality levels of patients with bipolar disorder I and II, Neuropsychiatric Disease and
Treatment, , 177-184, DOI: 10.2147/NDT.S90596
To link to this article: https://doi.org/10.2147/NDT.S90596
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Open access Full Text article
The differences in temperament–character traits,
suicide attempts, impulsivity, and functionality
levels of patients with bipolar disorder i and ii
Filiz izci 1
Ebru Kanmaz Fındıklı 2
Serkan Zincir 3
Selma Bozkurt Zincir 4
Merve iris Koc 4
1
Department of Psychiatry, school
of Medicine, istanbul Bilim University,
istanbul, 2Department of Psychiatry,
school of Medicine, Kahramanmaras
sutcu imam University,
Kahramanmaras, 3Department of
Psychiatry, Kocaeli Gölcük Military
hospital, Kocaeli, 4Department of
Psychiatry, Erenköy Training and
research hospital for Psychiatric
and Neurological Disorders, Istanbul,
Turkey
correspondence: Filiz izci
Department of Psychiatry, school of
Medicine, istanbul Bilim University,
164 abide-i hurriyet cad, istanbul 34100,
Turkey
Tel +90 505 450 3013
email filizizci@yahoo.com
Background: The primary aim of this study was to compare the differences in temperament–
character traits, suicide attempts, impulsivity, and functionality levels of patients with bipolar
disorder I (BD-I) and bipolar disorder II (BD-II).
Methods: Fifty-two BD-I patients and 49 BD-II patients admitted to Erenköy Mental and
Neurological Disease Training and Research Hospital psychiatry clinic and fifty age- and sexmatched healthy control subjects were enrolled in this study. A structured clinical interview for
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Axis I Disorders, Temperament and Character Inventory, Barrett Impulsiveness Scale-11 (BIS-11), Hamilton Depression
Inventory Scale, Young Mania Rating Scale, and Bipolar Disorder Functioning Questionnaire
(BDFQ) were administered to patients and to control group.
Results: No statistically significant difference in sociodemographic features existed between
the patient and control groups (P.0.05). Thirty-eight subjects (37.62%) in the patient group
had a suicide attempt. Twenty-three of these subjects (60.52%) had BD-I, and 15 of these
subjects (39.47%) had BD-II. Suicide attempt rates in BD-I and II patients were 60.52% and
39.47%, respectively (P,0.05). Comparison of BD-I and II patients with healthy control
subjects revealed that cooperativeness (C), self-directedness (Sdi), and self-transcendence
(ST) scores were lower and novelty seeking (NS1 and NS2), harm avoidance (HA4), and
reward dependence (RD2) subscale scores were higher in patients with BD-I. When BD-I
patients were compared with BD-II patients, BIS-11 (attention) scores were higher in patients
with BD-II and BIS-11 (motor and nonplanning impulsivity) scores were higher in patients
with BD-I. According to BDFQ, relations with friends, participation in social activities,
daily activities and hobbies, and occupation subscale scores were lower and taking initiative
subscale scores were higher in patients with BD-I. Social withdrawal subscale scores were
higher in patients with BD-II.
Conclusion: In our study, NS, HA, and RD scores that may be found high in suicide attempters
and Sdi scores that may be found low in suicide attempters were as follows: NS1, NS2, HA4,
and RD2 subscale scores were high and Sdi scores were low in patients with BD-I, suggesting
a higher rate of suicide attempts in this group of patients. In addition, C and Sdi scores that
indicate a predisposition to personality disorder were significantly lower in patients with BD-I
than patients with BD-II and healthy controls, suggesting a higher rate of personality disorder
comorbidity in patients with BD-I. Higher impulsivity and suicidality rates and poorer functionality in patients with BD-I also suggest that patients with BD-I may be more impulsive and
more prone to suicide and have poorer functionality in some areas.
Keywords: bipolar disorder I and II, temperament and character, suicide, impulsivity,
functionality
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http://dx.doi.org/10.2147/NDT.S90596
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izci et al
Introduction
Bipolar disorder (BD) is a mental disorder characterized by
manic, depressive, and mixed episodes, and life-expectancy
has been found to be much shorter in patients, with BD prevalence of BD-I and BD-II being 0.8% and 0.5% respectively.1,2
BD is divided into BD-I, BD-II, cyclothymic disorder, and
BD not otherwise specified (NOS) subgroups according to
Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition (DSM-IV) classification system.3 In a study examining
Bipolar spectrum disorders among 300 patients, BD rate was
found to be high and a majority of the BD cases had BD-II.4
The presence of other Axis I disorders, alcohol and substance
use, rapid cycling, early onset of bipolar, a family history of
suicide attempts, and severe mixed and depressive episodes
may constitute risk factors for suicide attempts in patients with
BD.5 Patients with BD have a suicide rate that is 30 times higher
than the general population, and 15%–25% of bipolar patients
attempt suicide. Fifteen percent of those who attempted suicide
succeed in ending their lives.6 Although no difference exists
in attempted suicide rates between BD-I and BD-II patients,
BD-II patients tend toward more lethal suicide attempts.7
Personality disorder comorbidity in patients with
psychiatric disorders has been reported to increase the risk
of suicide.8,9 Personality traits are among the many predictors
of suicide in patients with BD.10 Cloninger has developed
a dimensional psychobiological model of personality that
accounts for two major components of personality: temperament and character traits. Cloninger’s psychobiological
theory of personality contains four temperament dimensions
including novelty seeking (NS), harm avoidance (HA),
reward dependence (RD), and persistence (P) along with
three character dimensions including self-directedness
(Sdi), cooperativeness (C), and self-transcendence (ST).
Temperament dimensions reflect biological, hereditary
aspects of personality. Temperament is distinguished from
character by individual differences in interpersonal relationships and object relations. Meanwhile, life events, culture,
and social learning mold character dimensions.11–14 BD
patients have higher novelty-seeking scores and lower persistence scores than depressive patients and normal subjects.15,16
Higher NS scores may predict impaired functioning.17 In
addition, current research findings show that specific temperament types (depressive, cyclothymic, hyperthymic,
irritable, and anxious) are the subsyndromal (trait-related)
manifestations and commonly the antecedents of minor and
major mood disorders. Up to 20% of the population has some
kind of marked temperaments; depressive, cyclothymic, and
anxious temperament is more frequent in women, whereas
hyperthymic and irritable temperaments predominate among
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men. Premorbid temperament types have an important role
in the clinical evolution of minor and major mood episodes
including the direction of the polarity and the symptom
formation of acute mood episodes. They can also significantly
affect the long-term course and outcome including suicidality
and other forms of self-destructive behaviors.18 More than
81% of the patients with prevailing cyclothymic–depressive–
anxious temperament had mild-to-severe suicidal risk on the
MINI versus only around 42% of the patients with prevailing
hyperthymic temperament.19 Here, we aimed to compare a
history of attempted suicide, temperament character traits,
impulsivity, and levels of functionality in BD-I and BD-II
patients admitted to our outpatient clinic.
Patients and methods
sample
Fifty-two patients diagnosed with BD-I and 49 patients
diagnosed with BD-II using a structured interview for
DSM-IV Axis I Disorders (SCID-I/CV) who were admitted
to the outpatient psychiatry clinic of the Erenköy Mental
and Neurological Diseases Training and Research Hospital
between March 2013 and August 2013 were enrolled in this
study. Also 50 age- and sex-matched healthy control subjects who met the study criteria and had no history of any
psychiatric or neurological disease were included. Verbal
and written informed consent was taken from the patient and
control group. The study was started after the approval of
Ethics Committee of Erenköy Psychiatric and Neurological
Diseases Training and Research Hospital.
Individuals who were between 18 and 60 years old, literate
enough to understand written documents, diagnosed with BD
according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), in remission at
least for 2 months with a Hamilton Rating Score of Depression
(HRSD) lower than 7, and a Young Mania Rating Scale (YMRS)
score lower than 5 were included. Impulsivity and temperament
characteristics were evaluated during remission.
We excluded from the study patients with mental retardation, alcohol and drug-abuse related disorders, anxiety disorders, schizophrenia and other psychotic disorders, dementia
and other cognitive disorders, and neurological disorders with
unique personality traits such as epilepsy, migraine, multiple
sclerosis, and Parkinson’s disease, as well as systemic disorders leading to cognitive impairment or affecting vision,
hearing, or motor skills.
Materials
We assessed all patients and controls using a semistructured
sociodemographic data form based on clinical experience
Neuropsychiatric Disease and Treatment 2016:12
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and an investigation of the literature, structured clinical
interview for DSM-IV SCID-I, Temperament and Character
Inventory (TCI), and Barratt Impulsivity Scale 11 (BIS-11).
Additionally, Hamilton Depression Rating Scale, YMRS, and
Bipolar Disorder Functioning Questionnaire (BDFQ) were
administered to the patient group.
Data collection tools
Sociodemographic and clinical information
Sociodemographic and clinical information was collected
using a questionnaire consisting of some questions regarding
age, sex, marital status, educational level, and economic status, for patients with BD-I, BD-II, and the control group.
structured clinical interview for DsM-iV/clinical Version
This structured interview was developed by First et al20 in
1995 to determine the presence or absence of DSM-IV Axis I
disorders. Çorapçıoğlu conducted a validation and reliability
study for the Turkish version in 1999.21
Temperament and character inventory
The TCI is a 240-item, self-report questionnaire with trueor-false statements developed to assess personality. The
TCI consists of seven higher-order scales. The temperament
dimensions of NS, HA, and RD are each divided into four
subscales, while the character dimensions of Sdi and cooperativeness (C) are each divided into five subscales. In addition,
ST is divided into three subscales.11 Köse et al22 conducted
the validation and reliability study for the Turkish version
of the inventory in 2004.
Barratt impulsiveness scale-11
This is a 30-item self-report measure intended to assess
impulsivity in which the individual marks the most appropriate answers to a series of questions from the alternatives,
“rarely/never, occasionally, often, and almost always/
always.” A factor analysis indentified three second-order
factors: 1) attentional impulsivity, 2) motor impulsivity,
and 3) nonplanned impulsivity. Higher scores indicate higher
levels of impulsivity.23 Güleç et al24 conducted the validation
and reliability study for the Turkish version in 2008.
Hamilton Rating Scale for Depression
This is the most widely used scale for assessing depression
severity and was developed by Williams in 1978.25 The sum
of the scores obtained from each item provide the total score.
Scores below 7 indicate no depression, scores between 7 and
17 indicate moderate depression, scores between 18 and 24
indicate heavy depression, and scores $25 indicate severe
Neuropsychiatric Disease and Treatment 2016:12
The differences in temperament–character traits
depression. Akdemir et al26 conducted the validation and
reliability study for the Turkish version in 1996.
Young Mania Rating Scale
Young et al27 developed this scale, which is widely used to
assess the intensity of manic symptoms. The scale consists of
eleven items. Seven of them have five Likert-type items and
four of them have nine Likert-type items. The lowest score
that can be obtained from the scale is 0, while the highest
score is 44. The validity and reliability of the Turkish version
has been tested by Karadağ et al.28 The cut-off score was not
calculated during the Turkish version’s validity and reliability
study. Here, we compared both total scores and single-item
scores according to sex.
Bipolar Disorder Functioning Questionnaire (BDFQ)
This is a 52-item self-report measure intended to assess the
functionality of bipolar patients during symptomatic periods
or recovery. Aydemir et al29 developed the questionnaire that
consists of eleven subscales, including emotional functioning, intellectual functioning, sexual functioning, stigmatization feelings, social withdrawal, household relations,
relations with friends, participation in social activities, daily
activities and hobbies, initiative taking, self-sufficiency,
and occupation. Because the cut-off score could not be
calculated, it was recommended for use in comparative
studies.29
statistical analysis
“SPSS for Windows 8.0” (SPSS Inc., Chicago, IL, USA)
was used for data analysis. Chi-square test was used to
evaluate the relationship between categorical variables.
After testing for homogeneity and normality of variances,
Student’s t-test was performed to evaluate the difference
between temperament and impulsivity. One-way analysis of
variance (ANOVA) and Tukey post hoc test were performed
to evaluate the patient subgroups. Results were evaluated at
95% confidence interval and significance was evaluated at
P,0.05.
Results
Fifty-two patients diagnosed with BD-I and 49 patients
diagnosed with BD-II according to the DSM-IV-TR and
50 age- and sex-matched controls were enrolled in this
study. The mean age in the patient and control groups was
35.69±12.10 years and 32.00±9.24 years, respectively. There
was no statistically significant difference between the patient
and control groups in terms of sociodemographic properties
(P.0.05; Table 1). Thirty-eight (37.62%) subjects in the
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izci et al
Table 1 Sociodemographic characteristics of the patients and
controls
Patient
(N=101)
Age (mean ± SD)
35.69±12.10
Sex
Male
71 (70.3)
Female
30 (29.7)
Educational status
Primary school
34 (33.6)
High school
32 (31.7)
University
35 (34.7)
Marital status
Married
41 (40.6)
Single
60 (59.4)
Occupational status
employed
67 (66.3)
Unemployed
27 (26.7)
student
7 (6.90)
Control
(N=50)
Statistic
χ2
P-value
32.00±9.24
1.89
0.06*
30 (60.0)
20 (40.0)
1.60
0.20*
5.40
0.06*
with BD-I, BD-II, and healthy controls, there was a statistically significant difference between the groups in terms of ST
subgroups (ST1, ST2; respectively, F=9.91, P,0.00; F=15.66,
P,0.00) and total ST scores (F=8.43, P,0.00; Table 3).
According to the BIS-11, motor impulsiveness and
nonplanning impulsiveness subgroup scores were found
to be statistically significantly higher in patients with
BD-I (respectively, F=21.04, P,0.00; F=23.88, P,0.00).
However, attentional impulsiveness subgroup score was
1.60
0.20*
Table 3 comparison of Tci scores of patients with BD-i, BD-ii,
and healthy controls
10.94
0.06*
8 (16.0)
15 (30.0)
27 (54.0)
18 (36.0)
32 (64.0)
30 (60.0)
10 (20.0)
10 (20.0)
Notes: *P.0.05. Data presented as number (%).
Abbreviation: sD, standard deviation.
patient group had a suicide attempt and 23 (60.52%) of these
patients were diagnosed with BD-I and 15 (39.47%) were
diagnosed with BD-II (Table 2).
Suicide attempt rates of BD-I and BD-II patients were
60.52% and 39.47%, respectively (P,0.05; Table 2).
Within temperament dimension, in the comparison of the
patients with BD-I, BD-II, and healthy controls, there was
a statistically significant difference between the groups in
terms of NS (NS1 and NS2; respectively: F=6.17, P,0.05;
F=16.32, P,0.00), HA4 (F=6.83, P,0.05), and RD (RD2;
F=8.80, P,0.01).
Within character dimension, in the comparison of the
patients with BD-I, BD-II, and healthy controls, there was a
statistically significant difference between the groups in terms
of Sdi subgroups (Sdi1, Sdi2, Sdi3, Sdi5; F=11.72, P,0.05;
F=23.05, P,0.00; F=14.64, P,0.00; F=19.97, P,0.00), total
Sdi (F=17.55, P,0.00), C subgroups (C1, C2, C3, C4, C5;
respectively, F=7.36, P,0.05; F=6.68, P,0.05, F=13.13,
P,0.00; F=6.11, P,0.05, F=12.69, P,0.00), and total C
scores (C; F=17.55, P,0.00). In the comparison of patients
Table 2 comparison of suicide attempt rates of patients with
BD-i and BD-ii
The group of The group of Statistic
patients with patients with χ2
P-value*
BD-I (N=52) BD-II (N=49)
Suicide attempt (+), 23 (60.52)
(N, %)
Suicide attempt (-), 29 (46.03)
(N, %)
15 (39.47)
34 (53.96)
1.70 0.019
Note: *P,0.05.
Abbreviations: BD-i, bipolar disorder i; BD-ii, bipolar disorder ii.
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BD-I
(N=52)
Novelty seeking
Ns1
6.06±1.76
Ns2
4.88±2.02
Ns3
5.48±2.35
Ns4
4.09±1.89
Total
20.51±8.02
Harm avoidance
ha1
6.18±2.32
ha2
3.75±1.81
ha3
3.42±2.35
ha4
4.65±2.33
Total
18.00±8.81
Reward dependence
rD1
6.68±2.16
rD2
4.92±1.79
rD3
2.80±1.30
Total
14.40±3.69
Persistence
P
4.81±1.86
Self-directedness
sD1
4.19±1.86
sD2
4.86±1.58
sD3
2.66±1.39
sD4
5.24±2.81
sD5
6.45±2.06
Total
22.77±7.43
Cooperativeness
c1
5.29±2.00
c2
3.93±1.22
c3
4.34±1.45
c4
6.29±2.54
c5
6.42±1.58
Total
26.27±8.79
Self-transcendence
sT1
6.30±2.76
sT2
5.23±2.14
sT3
7.06±2.66
Total
18.59±7.98
BD-II
(N=49)
Controls
(N=50)
Statistics
Fa
P-value
5.31±2.11
4.22±2.00
4.46±2.34
4.24±1.92
18.23±8.37
6.34±2.03
3.14±1.97
4.88±1.49
4.24±1.66
18.60±4.83
6.17
16.32
3.68
0.37
0.82
0.04*
0.00*
0.15
0.82
0.71
5.09±2.44
3.72±1.54
2.81±2.25
4.26±1.91
15.88±8.14
5.02±2.05
3.64±1.50
3.08±1.38
3.48±1.52
15.22±3.72
5.20
0.39
1.51
6.83
2.73
0.07
0.81
0.46
0.03*
0.24
7.47±1.72
4.21±1.65
2.45±1.20
14.15±3.08
7.37±1.66
3.85±1.68
2.27±1.30
13.56±2.66
3.11
8.80
4.41
1.99
0.21
0.01*
0.11
0.36
5.41±2.53
5.16±1.85
0.82
0.66
4.24±2.27
5.25±1.75
2.88±1.56
5.53±2.23
6.61±2.38
24.72±8.16
5.58±1.73
6.58±1.57
3.78±1.09
5.76±2.55
8.40±1.93
30.10±6.22
11.72
23.50
14.64
0.75
19.97
17.55
0.03*
0.00*
0.00*
0.68
0.00*
0.00*
6.03±1.51
4.16±1.26
5.00±1.23
7.75±1.64
6.51±1.73
29.45±7.37
6.46±1.40
4.70±1.32
5.48±1.18
6.82±1.99
7.54±1.03
31.00±4.12
7.36
6.68
13.13
6.11
12.69
6.83
0.02*
0.03*
0.00*
0.04*
0.00*
0.00*
7.03±2.61
6.00±2.25
8.29±2.97
21.32±7.83
5.26±2.34
4.06±1.95
7.30±3.11
16.62±6.03
8.91
15.66
3.40
8.43
0.00*
0.00*
0.18
0.00*
Notes: F, aNOVa test value. aPost hoc assessment Tukey test. *P,0.05. Data
presented as mean ± standard deviation.
Abbreviations: BD-i, bipolar disorder i; BD-ii, bipolar disorder ii; aNOVa,
analysis of variance; Tci, temperament and character inventory.
Neuropsychiatric Disease and Treatment 2016:12
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The differences in temperament–character traits
Table 4 comparison of impulsivity in patients with BD-i and BD-ii
BIS-11
Patients
Patients
Controls Statistics
with BD-I
with BD-II
Fa
P-value
(mean ± SD) (mean ± SD)
Total
Nonplanned
Motor
attentional
70.80±23.24
30.69±27.59
23.00±5.36
17.11±4.25
65.27±12.32
25.02±4.92
22.85±6.43
17.40±4.87
57.08±9.56
22.66±3.77
18.82±4.66
14.38±3.12
22.17
23.88
21.04
15.31
0.00*
0.00*
0.00*
0.00*
Notes: F, aNOVa test value. aPost hoc assessment Tukey test. *P,0.05.
Abbreviations: BD-i, bipolar disorder i; BD-ii, bipolar disorder ii; aNOVa, analysis
of variance; Bis-11, Barrett impulsiveness scale-11.
found to be statistically significantly higher in patients with
BD-II (F=15.31, P,0.00; Table 4).
Patients with BD-I had lower scores than patients with
BD-II in relations with friends, participation in social
activities, daily activities and hobbies, and occupation subscales on the BDFQ (P,0.05, P,0.05, P,0.01, P,0.01,
respectively). While the social withdrawal subscore was
higher in patients with BD-II (P,0.05), taking initiative and
self-sufficiency subscores were higher in patients with BD-I
(P,0.05; Table 5).
Discussion
The risk of suicide attempts among psychiatric disorders was
identified as highest in patients with mood disorders (60%).
Twenty percent of those with BD die by suicide, as compared to 15% of those with major depressive disorder, 18%
of those with alcoholism, 10% of those with schizophrenia,
and 5%–10% of those with Axis II disorders.30,31 Thirtyeight (37.62%) patients in our study had attempted suicide.
Table 5 Comparison of functioning in patients with BD-I and BD-II
BDFQ
BD-I
(N=52)
BD-II
(N=49)
Statistics
t
P-value
Emotional functioning
Intellectual functioning
Sexual functioning
Feelings of stigmatization
social withdrawal
household relations
relations with friends
Participation to social
activities
Daily activities and hobbies
Taking initiative and self
sufficiency
Occupation
3.62±1.13
4.51±1.07
3.76±1.96
3.19±2.23
2.88±1.61
6.16±2.89
4.90±2.46
7.47±3.50
3.85±1.09
4.22±1.04
3.97±2.09
3.44±2.32
3.68±1.56
6.42±3.08
6.75±2.45
9.20±4.39
-0.9
1.22
-0.46
-0.5
-2.26
-0.38
-3.39
-1.97
0.52
0.13
0.68
0.56
0.03*
0.86
0.02*
0.04*
4.34±2.24
2.62±1.44
6.35±3.70
1.67±1.87
-2.96
2.22
0.01**
0.03*
4.42±1.48
5.16±1.67
-2.03
0.01**
Note: *P,0.05, **P,0.01.
Abbreviations: BDFQ, Bipolar Disorder Functioning Questionnaire; BD-I, bipolar
disorder i; BD-ii, bipolar disorder ii; sD, standard deviation.
Neuropsychiatric Disease and Treatment 2016:12
Of patients who attempted suicide, 23 (60.52%) had BD-I
and 15 (39.47%) had BD-II. Increased suicide rates may contribute to a lower life expectancy and quality of life. Suicide
attempt rates are 20–30 times higher in bipolar patients than
general population.32 In a study with bipolar and unipolar
depressive disorder patients, high suicide risk was found in
more than 52% of the patients and depressive anxiety symptoms, impulsivity, and hostility rates were higher in patients
with high suicidality risk.33
The coexistence of a personality disorder is present in
the majority of the patients who attempted suicide. In a
controlled study of patients with BD, a personality disorder
diagnosis according to the DSM IV was present in 48% of
bipolar patients.34 Given that the prevalence of personality
disorders among the general population is about 5.9%, personality disorder is significantly higher in patients with BD
than general population.35 Patients with personality disorder
were more likely to attempt suicide,36 both in our study and in
the literature.37 Similarly, character traits are one of the many
predictors for suicide attempts in patients with BD.
Studies examining the relationship between suicide
attempts and temperament and character traits have shown
that suicide attempters had lower Sdi32,33 and higher ST32–34
subscale scores within character dimension and higher
HA, NS, and RD subscale scores11,35 within temperament
dimension. Another study found a relationship between
higher HA scores and suicide attempts in patients with BD.38
Consistent with the literature, in our study, NS1, NS2, HA4,
and RD2 subscale scores are found to be higher and Sdi scores
are found to be lower in patients with BD-I than BD-II and
controls. For personality disorders, the rate of completed
suicide has been identified as 29%–57%.39 Slama et al40 have
proposed that low Sdi and C scores could possibly predict the
development of a personality disorder. In our study, lower Sdi
and C scores in patients with BD-I than patients with BD-II
and controls suggest that personality disorder coexistence
may occur more frequently in patients with BD-I.
In the literature, suicide risk factors for patients with BD-I
and BD-II include a family history of suicide attempts, early
onset of BD, frequent depressive symptoms, alcohol and substance abuse, social phobia features, antidepressant-induced
mania, and a history of head trauma. No statistically significant differences were found in terms of suicide ideation and
attempts between patients with BD-I and BD-II.41,42 Suicideattempt rates were higher in patients with BD compared to
patients with unipolar depressive disorder. Suicide-attempt
rates were also higher in patients with BD-II as compared to
BD-I.42 However in our study, 23 (60.52%) of 38 attempters
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izci et al
had BD-I, and 15 (39.47%) had BD-II. Other studies of BD
patients have identified that unipolar patients had higher NS10
and lower Sdi6 scores compared to healthy controls. In a similar study, patients with BD had higher NS scores than patients
with unipolar disorder and patients with bipolar and unipolar
disorder had higher HA scores than healthy controls.15
In our study, within temperament dimension, NS1, NS2,
HA4, and RD2 subscale scores were significantly higher in
patients with BD-I than BD-II and healthy controls. Within
character dimension, total Sdi scores, total C scores, and
subscale scores for both dimensions were significantly
lower in patients with BD-I than BD-II and healthy controls.
In addition, total ST scores and ST subscale scores were
significantly higher in patients with BD-II than BD-I and
healthy controls. Because Slama et al40 considered C and Sdi
scores as predictors of personality disorder, low C and Sdi
scores in patients with BD-I suggest that the coexistence
of personality disorder with BD could be more frequent in
patients with BD-I. NS indicates a hereditary predisposition
to exploratory activity in response to a new stimulus, impulsive decision making and irritability.12–14,38 Because in our
study NS scores were higher in patients with BD-I, we may
think that these patients may be more prone to impulsive
behaviors like suicide.
Two main differences emerged in bipolar patients with
and without a history of attempted suicide. One of these
differences was that suicide attempters had more subjective
depression and hopelessness, as well as more seriously suicidal ideations; they also displayed lifelong reactionary and
aggressive tendencies. Patients who had attempted suicide
were more impulsive in decision making and interpersonal
relationships.43,44 Lifelong aggression levels were higher in
patients with suicide attempts, but impulsivity levels were
similar between the two groups.45 In our study, both motor
and nonplanned impulsivity scores were higher in patients
with BD-I than BD-II. In the manic phase, impulsivity is
characterized by unplanned and motor impulsivity, whereas
in the depressive phase, it is characterized again by unplanned
impulsivity. Attentional impulsivity is present in BD-II.
Impulsive behaviors such as suicide attempts usually occur
in the depressive phase of BD.46,47 In our study, in concordance with literature, motor and nonplanned impulsivity was
pronounced in patients with BD-I and attentional impulsivity
was pronounced in patients with BD-II.
In the BDFQ, social withdrawal, relationships with
friends, participation in social activities, daily activities
and hobbies and occupation subscale scores were lower in
patients with BD-I than BD-II, and only initiative-taking
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subscale scores were significantly higher in patients with
BD-I than BD-II. BD adversely affects nearly every area
of life and reduces overall functionality.48 Two studies
investigating the differences between the psychosocial
functioning of patients with BD-I and BD-II have shown that
similar disabilities were present during both their euthymic
and depressive periods.49,50 A recent meta-analysis showed
similar levels of deterioration in cognitive functioning in
euthymic patients with BD-I and BD-II. Euthymic patients
with BD experience cognitive deficits, especially in executive
functioning, working memory, and attention.51 In our study,
patients with BD-I had a more corrupted functionality in
social activities and relationships than patients with BD-II.
study limitations
Our study has several limitations, including its crosssectional design, the relatively small subject numbers, and
the exclusive use of self-report questionnaires. Although
it is not possible to establish direct causal relationships or
determine predictive factors with these findings, our results
are noteworthy in terms of being descriptive of the clinical
characteristics of our patient population.
Conclusion
Suicide attempts in patients with BD-I and -II significantly
affect individual’s life and functionality. Early diagnosis,
individual assessment of symptomatology, and the establishment of a treatment process are the most important factors.
Our study has shown that impulsivity and risk of attempting
suicide are higher in patients with BD-I than BD-II. In addition, patients with BD-I are found to have poorer functionality than patients with BD-II. High NS1, NS2, HA4, RD2
subscale scores and low Sdi and C scores may be related to
suicide attempts. Higher motor and nonplanned impulsivity
scores in patients with BD-I than BD-II suggest that these
may be facilitating factors for an impulsive behavior like
suicide. Identifying impulsivity, suicide attempts, temperament–character traits, and functionality in patients with BD-I
and BD-II will be useful in the diagnosis and treatment of
disease progression.
Disclosure
The authors report no conflicts of interest in this work.
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