The Relationship of Personality
to Affective Disorders
A Critical Review
Hagop S. Akiskal, MD; Robert M. A. Hirschfeld, MD; Boghos I.
\s=b\ Although characterologic constellations such as obses-
sionalism, dependency, introversion, restricted social skills,
and maladaptive self-attributions are popularly linked to the
pathogenesis of depressive disorders, the evidence in support
of this relationship remains modest. Indeed, many of these
attributes may reflect state characteristics woven into the
postdepressive personality. Current evidence is strongest for
introversion as a possible premorbid trait in primary nonbipo-
lar depressions. By contrast, driven, work-oriented obsessoid,
extroverted, cyclothymic, and related dysthymic tempera-
ments appear to be the precursors of bipolar disorders. Other
personalities, while not necessarily pathogenic in affective
disorders, nevertheless may modify the clinical expression of
affective disorders and their prognosis.
(Arch Gen Psychiatry 1983;40:801-810)
physicians conceptualized illness, including
Hippocratic
melancholia,
premorbid
in dimensional terms as an
characteristics.1 In modern
outgrowth of
times, full-scale
application of this dimensional concept to psychiatric disor¬
ders led Kretschmer to hypothesize that the "endogenous
psychoses are nothing other than marked accentuation of
normal types of temperament."2 This line of reasoning is
also typical of dynamic thinking that considers manifest
psychopathology as the symptomatic expression of charac-
terologic tendencies of developmental origin.3 Thus, it is
Accepted for publication Nov 29, 1982.
From the Affective Disorders Program, Departments of Psychiatry
(Drs Akiskal and Yerevanian) and Pharmacology (Dr Akiskal), University of
Tennessee College of Medicine, Memphis; Sleep Disorders Center, Labora-
tory of Neurophysiology, Baptist Memorial Hospital, Memphis (Dr Akis-
kal); and the Clinical Research Branch and Center for the Study of Affective
Disorders, National Institute of Mental Health, Alcohol, Drug Abuse and
Mental Health Administration, Rockville, Md (Dr Hirschfeld). Dr Yereva-
nian is now with the Affective Disorders Unit, Department of Psychiatry,
University of Rochester, NY.
Reprint requests to Suite 633, Department of Psychiatry, University of
Tennessee, 66 N Pauline St, Memphis, TN 38163 (Dr Akiskal).
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Yerevanian, MD
widely believed that psychopathologic states arise from
enduring, preexisting, and predisposing traits that con¬
stitute the premorbid personality. However, while depres¬
sive episodes may be superimposed on cyclothymic, dys-
thymic, dependent, or compulsive personalities, affective
psychoses may also arise out of personality structures that
are either unremarkable or insufficiently deviant to war¬
rant personality diagnoses.4,5
The postulated relationship between personality and
affective states has been developed largely from clinical
reconstruction of the premorbid histories of patients stud¬
ied during, or subsequent to, an illness episode.6 Although
these clinical approaches have generated valuable insights,
they have been subject to the bias inherent in such meth¬
ods.7 The assumption that personality disturbance precedes
affective episodes has yet to be demonstrated in large-scale,
rigorous prospective research. In fact, current evidence
suggests that such disturbance not uncommonly represents
the sequel of incompletely remitted affective episodes.8"11
This critical assessment of the relationship between
personality and affective illness will focus on previous
research efforts conducted within these méthodologie con¬
straints (as well as attempts to circumvent them), and on
emerging clinically relevant findings about this complex
relationship. The literature review is selective, chosen to
highlight specific méthodologie issues.
TERMINOLOGIC AND CONCEPTUAL ISSUES
Terms like temperament, character, and personality have
been used almost synonymously to subsume more or less
enduring response sets. The term temperament, long asso¬
ciated with humoral theory, is best reserved for genetically
or constitutionally determined tendencies. Character, by
contrast, generally refers to the learned attributes orig¬
inating in developmental experiences within the family
structure. Of the three terms, personality has the broadest
meaning, embracing the joint contribution of inborn tem¬
peramental and acquired characterologic determinants of
 psychologie and behavioral traits. Within this definition,
personality disturbances can be incidental to, causative in,
or a sequel of adult psychiatric disorders. Just as one can
speak of personality disturbances that are secondary to the
experience of a disabling medical disorder, it is legitimate to
speak of personality disturbances secondary to affective
disorder; these sequelae could be short term or long term.
However, in clinical discussions, developmentally ac¬
quired components of personality are usually given more
weight. Despite Freud's statement that "endowment and
chance determine a man's fate—rarely or never one of these
powers alone,"12 the psychogenetic point of view has domi¬
nated the conventional psychologic literature.3,13 Current
evidence indicates that hereditary-genetic factors do con¬
tribute to personality development; according to Körner, "it
is likely that genetic differences in the biologic sense create
genetic differences in the psychoanalytic sense."14 Ben¬
jamin has gone so far as to state that "not only can innate
differences in drive organization, in ego functions, and in
maturational rates determine different responses to objec¬
tively identical experiences, but they can also help deter¬
mine what experiences will be experienced."15
The most compelling evidence for the contribution of
heredity to personality formation is provided by adoption
studies. For instance, the adopted-away offspring of so-
ciopathic persons, who share their biologic parents' genes
but are reared by nonsociopathic adoptive parents, have a
rate of personality disorder that exceeds the risk in the
general population.16 Monozygotic-dizygotic differences
have suggested that heredity significantly contributes to
the introversión-extraversión dimension17 and to "orality"
in men and hysterical traits in women.18 By contrast, it has
been reported that low self-confidence, shyness, passive-
dependence, and depressive tendencies exceed chance ex¬
pectation in the daughters of alcoholics only when raised
with their biologic fathers, suggesting that developmental
experiences are the dominant determinants for such traits
in this group.19 Many of these issues are reviewed by
Rainer.20
Other approaches that may provide insight into biologic
contributions involve the demonstration that certain per¬
sonality types are strongly correlated with certain biologic
markers characteristic of primary affective disorders.21 For
instance, recent studies have shown that subgroups of pa¬
tients with characterologic depression22 and borderline
personality23 have rapid eye movement (REM) latencies in
the range for primary depressives, but significantly shorter
than those of noncase and nonaffective personality controls.
Other proposed research strategies include familial loading
for primary affective disorders, unequivocal response to
such interventions as tricyclic antidepressants, monoamine
oxidase (MAO) inhibitors, lithium carbonate, or sleep
deprivation. For instance, cyclothymic personalities were
found to have a significantly higher proportion of manic-
depressive biologic kin than a nonaffective personality
disorder group.24 Brief hypomanic responses to tricyclic
antidepressants25 or sleep deprivation26 are largely limited
to primary mood disorders, and can therefore be used clini¬
cally to distinguish affectively based dysthymic tempera¬
ments22,27 from the large universe of chronically dysphoric
characterologic disturbances subsumed under the broad
rubric of dysthymia in DSM-III.28 Likewise, Klein et al29
have argued that "hysteroid dysphoria" has a strong bio¬
logic core because of its responsivity to MAO inhibitors.
Finally, unequivocal response of patients with personality
disorders to lithium carbonate in a placebo crossover design
lends modest support to the contention that certain person-
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ality patterns are the expression of a major affective dis¬
position. Periodic anger outbursts30 and periodic obsessio¬
nal symptoms31 are reported to respond to lithium carbon¬
ate, suggesting their kinship to bipolar affective disorder.
However, monozygotic-dizygotic twin differences in rates of
obsessionalism have not provided unequivocal support for
hereditary contributions to this personality type.20
The foregoing considerations suggest that personality
and affective disorder are linked in a variety of ways.4,5
Authors in both the psychodynamic and behavioral tradi¬
tions have generally assumed that specific character traits
provide vulnerability to affective episodes; whether this
vulnerability is viewed as involving developmental fixation
points6 or deeply ingrained maladaptive self-attribu¬
tions,13,32 the evidence in its support has generally come
from retrospective reconstruction of personality attributes.
Other authors79 have limited their hypotheses to more
immediately observable relationships between personality
and affective illness, and have postulated that personality,
while not necessarily involved in pathogenesis, may never¬
theless modify the clinical expression or the outcome of the
illness. Neokraepelinian psychiatrists,2,4 on the other hand,
have taken the stand that the personalities observed in the
affectively ill represent either genetically attenuated tem¬
peramental forms of the illness or secondary social compli¬
cations of recurrently incapacitating affective episodes. We
shall next examine the evidence for each of these view¬
points.
THE CHARACTEROLOGIC PREDISPOSITION
TO AFFECTIVE EPISODES
In broad terms, this approach presupposes that certain
learned characterologic propensities are etiologic antece¬
dents of affective illness. Research in this area has ranged
from clinical explorations to studies employing sophisti¬
cated measurements.
Clinical Explorations
Early analytic investigations of the origins of psychiatric
syndromes emphasized constitutionally determined fixa¬
tion points, implicating faults in the maturation of key
biologic drives in etiology.33 Despite the astuteness of these
clinical observations and the eagerness to formulate etiol¬
ogy in the metabiologic language of the day, Freud and his
early followers were limited to a metapsychologic level of
discourse by the lack of the requisite biologic technology.
Abraham34 is usually credited as being the first to suggest
that persons prone to depressive episodes resembled obses¬
sional neurotics in having prominent "anal" traits, but
differed in having high levels of "oral" dependency. Abra¬
ham's report is prototypical of clinical-dynamic approaches
in the following ways: (1) affective disorder was treated as a
unitary condition, (2) insights gained from the clinical study
of six manic depressives were generalized, (3) neither the
dependent (affective state) nor the independent (character)
variable was measured by reliable, objective, and standard¬
ized instruments, (4) no control groups were utilized to test
the specificity of the character type to affective type, (5)
despite the fact that information about premorbid personal¬
ity was obtained retrospectively, it was postulated that
dynamics (condensed in a character diagnosis) precede
psychopathology (affective episodes), and (6) it was as¬
sumed that the co-occurrence of certain characterologic
traits and affective episodes indicated a causal relationship.
Abraham did not consider the possibility that they could
both spring from the same etiologic foundations.
Although some of these criticisms also apply to studies by
 Cohen et al,35 their focus on the predisposition to manic-
depressive illness, without generalizing to all depressions,
was a méthodologie advance. These authors hypothesized
that parental attitudes led to the development of ambitious,
driven, and extraverted persons who were superficially
well adjusted, but concealed strong dependency needs. As
the prestige bearers of the family, the life goals of these fu¬
ture manic-depressives were set very high, making them
highly susceptible to minor setbacks and prone to respond
with guilt and self-denigration. These findings were par¬
tially supported by Gibson.36 This formulation survived as
the prevalent clinical-dynamic explanation of the character¬
ologic predisposition to bipolar mood swings, despite Jacob-
son's warning37 that cyclothymic oscillations in mood were
"endogenous" or temperamental in nature.
Chodoff,6 reviewing the dynamic literature on the depres¬
sion-prone individual half a century after Abraham, con¬
cluded that a liberal mixture of obsessional and dependent
traits was the hallmark of such personalities. While this
hypothesis has some support in clinical observations, it
cannot be proved by clinical disquisition. However, Chodoff
did recognize many of the méthodologie inadequacies of the
early analytic approaches, and paved the way to modern
formulations. Persons prone to depression are viewed as
highly dependent on narcissistic supplies from others to
maintain their self-regard; hence, they have a lowered
threshold for developing depression when such supplies are
withdrawn as a result of adult object loss. Thus, Arieti and
Bemporad3 conceptualized depression as a derivative of
unsatisfactory intimacy in early attachment leading to self-
esteem that is exquisitely vulnerable to adult viscissitudes:
the depressive finds himself unloved, yet clings to love
objects whom he expects to be all-giving. Strupp et al38 have
recently expressed similar views. In the extreme, the
depressive character is considered to be a "love addict,"
intolerant of any withdrawal of romantic attachments in
adult life, reminiscent of the "hysteroid dysphoric" women
described by Liebowitz and Klein39; their short-lived, non-
autonomous, crushlike reactions occur in the setting of
histrionic and self-centered demeanor characterized by
flamboyance, exhibitionism, intrusiveness, seductiveness,
demandingness, and suicide gestures.
These views are concordant with Bowlby's conceptualiza¬
tion40 of depression as an expression of disrupted object
relations in early childhood. However, in his latest writings,
Bowlby41 suggests that breaks in early bonds are not
specific to clinical depression, but generic to a broad
spectrum of characterologic difficulties that underlie many
psychopathologic syndromes. Partial support for this posi¬
tion has come from studies showing that childhood loss of a
parent predicts high rates of suicide attempts.42,43 In brief,
breaks in early object relations seem to predict a general
characterologic disturbance distinct from clinical depres¬
sion11,27; the age at onset of these character disorder-based
dysphorias is typically early, dysphoric symptoms are often
described in hyperbolic terms, and clear-cut depressive
episodes with endogenomorphic coloring are uncharacteris¬
tic.
Another line of thinking about the characterologic vul¬
nerability depression can be traced from Freud's for¬
to
mulation of hostile introjects,44 to Klein's notions about the
depressive and paranoid positions,45 to contemporary ob¬
servations of depression manifesting in self-punitive cogni¬
tions in Judeo-Christian cultures and in paranoid-pro-
jective mechanisms in some African cultures.46 Why women
are presumably more vulnerable to these hostile-depend¬
ent, self-punitive, and "passive" stances that are hypoth-
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esized to underly minor depressions has received both
sociopsychologic (ie, "learned helplessness")47 and socio¬
biologie (ie, attachment as a critical evolutionary role for
women)48 interpretations.
In summary, psychoanalytic attempts to delineate the
characterologic matrix of affective disorders have suffered
from a number of méthodologie flaws. Also, they have been
more concerned with generating hypotheses than testing
hypotheses. Definitive testing of these views should be of
high priority given the influence they continue to exert on
clinical practice.
Psychometric Studies
Psychometric studies have generally avoided the méth¬
odologie problems of the psychoanalytic literature with one
exception: they are all retrospective.
Von Zerssen, in his review of the world literature,4
concluded that the "melancholic type" was characterized by
"orderliness, conscientiousness, meticulousness, high
value achievement, conventional thinking, and dependency
on close personal relationships." This pattern was typified
in the portrayal of the late-onset, usually psychotic, depres¬
sive as a self-critical, conscientious, hard-working, and
socially well-integrated person who had responded to adult
losses in a self-punitive and self-denigrating manner. These
findings were consistent across diverse cultural settings.
This essentially anankastic aspect of the melancholic
character has been supported by other authors. Cadoret et
al49 found that scores on the factor denoting "superego
strength" on CattelPs personality inventory were highest in
depressives with onset after the age of 40 years; scores were
also high in their "well" relatives compared with those of
early-onset depressive probands. Kendell and Discipio,50
who used the Leyton inventory51 to measure obsessionalism
during illness episodes and on clinical recovery in hospi¬
talized depressives, could not confirm the age association,
but did find that recovered unipolar (usually psychotic)
depressives had scores intermediate between those of ob¬
sessional neurotics and two groups of normal controls. In
addition, these authors suggested that manic episodes
rarely arose from the substrate of marked obsessionalism or
obsessional neurosis. This "protection" against mania ac¬
corded by marked premorbid obsessionalism strengthened
their argument that such traits were linked with unipolar
depressive illness. This study failed to confirm Videbech's52
and Gittleson's53,54 observations that obsessional symptoms
intensify during depression in premorbidly obsessional
persons; furthermore, even in nonobsessional persons,
obsessional symptoms seemed to develop during depres¬
sion, especially when depression was severe.
The inverse relationship between obsessionalism and
mania was not replicated in the National Institute of Mental
Health (NIMH) Collaborative Study on the Psychobiology
of Depression.55 Obsessionalism was in fact the only deviant
personality measure associated with mania: manies' scores
fell between those of obsessional neurotics and published
norms for the US population. This finding is consistent with
the observation that the extraverted, ambitious, and driven
person with an inordinate capacity for work—a profile
frequently linked to bipolar illness—has considerable af¬
finities to the duty-bound and work-addicted compulsive
person.5 Thus, the "syntonic" type, the Sjobring descrip¬
tion of the bipolar personality,56 overlaps considerably with
the "anankastic" (or compulsive) personality of the Anglo-
Saxon literature.57 This is not to say that a unitary personal¬
ity type characterizes the premorbid adjustment of bipolar
patients. Apart from the syntonic-anankastic type, "sub-
 stable" (extraverted or hyperthymic), cyclothymic, and
even dysthymic temperaments have been reported to pre¬
cede bipolar psychoses.2,22,24
Perris58 contrasted the "substable" personality of bipolar
depressives to the "sub valid" attributes of unipolar depres¬
sives. Subvalidity refers to persons who are bound to
routine, easy to tire, neurasthenic, cautious, tense, and
meticulous—a characterologic spectrum much wider than
obsessionalism.
Wittenborn and Maurer,59 who examined personalities at
the depth of depression and a year later on clinical recovery,
reported a wide range of neurotic characterologic traits
that persisted in many but not all apparently recovered
depressives, including (1) a tendency to blame others, (2) a
demanding and complaining attitude, (3) low self-confi¬
dence, and (4) a tendency toward moodiness and worry. The
authors concluded that in some patients the tendency
toward obsessional brooding and moodiness is state de¬
pendent and may temporarily persist as an interepisodic
manifestation of depressive illness; in others this tendency
may represent premorbid traits. It was further speculated
that intensification of obsessionalism and denial of anger at
the onset of a depressive episode may serve a defensive
function in a person overwhelmed by stress and preoc¬
cupied with the fear of losing control. Such reasoning has
led Telenbach60 to suggest that the traits of orderliness,
guilt, sociability, and concern for others are a defense
against depressives' tendency toward disorganization, hos¬
tility, and self-preoccupation, which represent their basic
or primary personality traits.
Metcalfe61 administered the Eysenck Personality Inven¬
tory (EPI) to women who had recovered from a severe
depression and compared them with controls without such
history. Although the overall neuroticism scores of the two
groups were similar, two personality attributes seemed to
characterize the experimental group: (1) worry and tense¬
ness, and (2) rigid, unimaginative, and "habit-bound" atti¬
tudes. The author concluded that the depressive is not
necessarily one who is prone to the development of depres¬
sion, but one who has difficulty recovering from such
illness. This interpretation is in line with Seligman's
"learned helplessness" hypothesis,47 and Lewinsohn's em¬
phasis on deficient social skills.62 However, deficits in in¬
strumental behavior are not necessarily antecedent person¬
ality attributes; insecurity, passive-dependence, and a gen¬
eral lack of social assertiveness could be secondary to the
experience of recurrently incapacitating episodes of de¬
pression.63 For the same reason, the cognitive triad of
hopelessness, helplessness, and self-denigration32 should be
regarded as epiphenomenal until it is shown prospectively
to antedate clinical depression. This sense of defeat and
demoralization29 is conceivably the final common pathway of
many neurotic and psychotic disorders, and may not be
specific to affective disorders.
The work of Beck, Seligman, and Lewinsohn has stimu¬
lated much research on the social and interpersonal roots of
depression. In addition to being retrospective, much of this
research13 has been based on nonclinical populations and/or
depressions falling short of syndromal criteria. Risk factors
described for such depressions64—female sex, loss of
mother during childhood, lack of intimate confiding rela¬
tionships, disinclination to seek help, and maladaptive self-
attributions—therefore may not apply to clinical (syndro¬
mal) depressions.65
It is apparent that méthodologie challenges in the area of
personalityand affective disorders are complex but not
insurmountable. Indeed, introversion and low sociability
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have emerged as relatively robust premorbid attributes in a
recent NIMH collaborative study (in progress).57 This study
is attempting to address the méthodologie limitations of
previous studies by comparing recovered primary nonbipo-
lar depressives with their recovered first-degree and never-
ill relatives and population controls.
In summary, predisposing characterologic traits for de¬
pressive illness have yet to be demonstrated in a prospec¬
tive design. The following attributes represent a distillate
of the current literature on the subject:55 (1) introversion, (2)
lack of self-confidence, (3) nonassertiveness, (4) deficiency
in social adroitness, (5) dependence, (6) tendency to worry
and obsessionalism, and (7) pessimism. Although such a
constellation may simply represent nonspecific personality
incompetence common to a wide variety of psychiatric
syndromes,66 we submit that the evidence reviewed impli¬
cates introversion in nonbipolar conditions, and extraver¬
sion and possibly obsessionalsim in bipolar disorders.
PERSONALITY AS A MODIFIER OF AFFECTIVE EPISODES
This viewpoint refrains from etiologic speculations re¬
garding personality and the pathogenesis of affective disor¬
der, limiting itself to the more observable impact of person¬
ality on the clinical picture, treatment, and outcome of
affective episodes (the so-called pathoplasty hypothesis). A
classic example of this approach is a study by Lazare and
Klerman67 in hospitalized depressed women that provided
evidence that certain traits modified the symptomatic
expression of the depressive episode. The obsessional
woman, overwhelmed by fear of loss of control, presented
an agitated and more severe depression than the hysteroid
character, whose demanding and seductive stance made her
appear less depressed than she actually was. One prediction
from this observation is that, contrary to the clinical
stereotype, persons with histrionic characters may suffer
from unrecognized severe depressions and even commit
suicide. Data from the University of Tennessee" support
this prediction. Also related to the Lazare-Klerman for¬
mulation is Bart's concept of "metadepression,"68 the deep¬
ening of depression in obsessional persons who subscribe to
the Anglo-Saxon work ethic and become demoralized be¬
cause of the limitations imposed by their depressive state.
Such persons tend to believe they are "weak" or "lazy"
rather than ill.
These data from various authors indicate that the charac¬
ter structure, while not necessarily pathogenic in affective
illness, may modify its symptomatic expression. Vaz Serra
and Polliti69 have recently supported such a position on the
basis of data showing high correlations between neuroti¬
cism scores on the EPI70 and the "psychologic" symptoms of
depression, and lack of correlation between such scores and
the "biologic" manifestations of depression. However, one
cannot conclude that neuroticism favors the occurrence of
psychologic symptoms; it is possible that both neuroticism
and psychologic symptoms reflect the same measure.
Personality factors may also determine prognosis or
treatment compliance. For example, it has been reported
that high neuroticism scores in depression correlate with
poor outcome.71 In another study, "unstable" character¬
ologic traits were considered the strongest predictor of
unfavorable social outcome in affective disorders.11 "Double
depressions,"72,73 ie, coexisting depressive personalities and
major depressive episodes defined by Research Diagnostic
Criteria,74 have also been shown to have poor outcome. It
would appear that in all of these studies, unfavorable
outcome reflects the unstable and neurotic traits measured
by the followup instrument rather than the failure of
 affective symptoms to resolve.
Outcome is also related to noncompliance, which is itself
largely determined by personality factors. For instance, it
has been suggested that noncompliance with lithium car¬
bonate therapy is most likely in predominantly hyper-
thymic bipolar patients who believe they achieve consider¬
able creativity during "highs."75,76
Finally, the characterologic disturbance may play an
indirect etiologic role by favoring the occurrence of life
events that precipitate depression in vulnerable individu¬
als, or creating interpersonal circumstances that maintain
the chronicity of depression. Some support for this sugges¬
tion was obtained by Weissman and Paykel," who noted that
impaired marital communication and related interpersonal
disturbances during illness episodes alienate spouses and
retard recovery from depression. Similar data have been
reported in a cohort of chronic primary unipolar depres¬
sives.77
PERSONALITY AS A COMPLICATION
OF AFFECTIVE ILLNESS
This approach is the converse of the clinical-dynamic
stand in that personality attributes of depressed subjects
are viewed as sequelae of affective illness. Within this
approach, however, one must distinguish between personal¬
ity changes during an affective episode, short-term inter¬
personal maladjustments following an affective episode,
and long-term personality changes resulting from recur¬
rent affective episodes.78
State-Dependent Changes
Significant personality disturbance has been found on a
variety of sensitive instruments administered during clini¬
cal depression; these measures tend to change toward
published norms on clinical recovery.55,79,80 For instance,
many Minnesota Multiphasic Personality Inventory scales
other than D (depression) are elevated during clinical
depressions;81 and neuroticism scores on the EPI are signifi¬
cantly elevated during depression and decreased in mania.55
Finally, comparing the same depressives during an episode
and following recovery, Hirschfeld et al63 reported signifi¬
cant drops in measures of orality and interpersonal de¬
pendency, suggesting that such traits are strongly state
dependent.
Personality change during mania82 is so flagrant that it
does not require sensitive instruments for documentation.
Janowsky et al83 reported that the "interpersonal maneu¬
vers" of manic patients, compared with those of other
psychotic patients, involved testing of limits, projection of
responsibility, detecting others' soft spots, attempts to
divide staff, flattering behavior, and ability to evoke anger.
Impulsive action (eg, in marital and financial matters) as a
result of poor judgment during both mania and depression82
is probably the most serious personality disturbance in the
acute phase of affective illness. Because such action reflects
psychotic disturbance rather than free choice, it is incum¬
bent on the clinician to prevent it, whenever feasible, by
direct and firm therapeutic approaches, eg, chemotherapy,
hospitalization, or urging the spouse or significant others to
take responsibility for finances.
Short-term Sequelae
The Weissman and Paykel study9 provided documentation
ofsignificant interpersonal dysfunction despite apparent
symptomatic recovery. Clinically recovered depressives
had incomplete resumption of marital roles, and were
unable to communicate appropriate assertiveness freely.
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These authors concluded that social recovery lagged behind
symptomatic recovery. It is possible, however, that these
interpersonal maladjustments in part reflect neurophysio-
logic disturbances that are now known to persist for many
months after symptomatic recovery.84 The practical implica¬
tions of these findings are to continue antidepressants for
eight to nine months beyond symptomatic improvement and
to provide short-term interpersonal psychotherapy.85,86
Chronic Sequelae
Cassano et al78 have recently distinguished between re¬
sidual affective symptoms, which may persist for a few
months after an acute episode and are often, although not
invariably, associated with short-term social maladjust¬
ment, and a permanent "depressive defect." The latter can
occur if environmental, psychological, or iatrogenic factors
impede the delicate recovery phase. Such chronic personal¬
ity changes are partly a continuation of the interpersonal
maladjustment seen during acute and residual illness
phases, and partly the psychologic consequence of demoral¬
ization,87 failure, insecurity, dependence, pessimism, and
an overall melancholy outlook resulting from repeated
illness episodes.88
Kraines,89 who devoted many years of prospective clinical
observation to the natural history of affective disorders
before the era of thymoleptic therapy, has described the
gradual evolution of postdepressive personality and neuro¬
tic complications. One common pattern includes patients
who are demanding, manipulative, and hostile; others are
irritable, chronically anxious, hypochondriacal, even ago¬
raphobic; another group is dependent and nonassertive; and
some patients become rigidly entrenched in work to the
exclusion of pleasure and social life. Obviously, a great deal
of overlap exists between these patterns.
These chronic sequelae of affective disorder occur pre¬
dominantly in high-episode frequency or chronic forms of
unipolar conditions. Such sequelae have been observed in
chronically depressed children who manifest hyperactivity
and conduct disorder.90,91 The interepisodic personality of
the manic or bipolar patient is often thought to be remark¬
ably nonneurotic, or free of characterologic disturbance.4,92
However, recent clinical observations*1"4 have documented
the existence of considerable characterologic disturbances,
leading to social deterioration, in the long-term course of
one third of bipolar patients.
PERSONALITY AS AN ATTENUATED EXPRESSION
OF AFFECTIVE ILLNESS
According to this approach, enduring personality pecu¬
liarities in affectively ill persons represent milder or alter¬
native expressions of the basic illness. A trait-state con¬
tinuum is postulated between premorbid personality and
clinical episodes, and it is assumed that both personality
and affective episodes are basically the expression of the
same genetic or constitutional endowment.
The Classic Typology
Kraepelin82 was among the first authors to pay systematic
attention to the premorbid characteristics of affectively ill
persons. In his attempt to account for the recurrence of
affective episodes, he postulated the existence of certain
enduring personality characteristics, from which the more
psychotic affective states arose. Thus, depressive, manic,
irritable (mixed), and cyclothymic (circular) personalities
were considered the temperamental bases of the respective
full-blown forms of the illness. Kraepelin's hypothesis was
based on the observation that affective temperaments oc-
 curred in the premorbid histories of the majority of manic-
depressive probands who returned to their basic tempera¬
ment rather than to "normality" on remission; furthermore,
such temperaments—without progression to full-blown
illness—were overrepresented in the biologic relatives of
manic-depressive probands.
Schneider's work95 on "psychopathic" (ie, deviant in a
statistical sense) personalities extended Kraepelin's obser¬
vations and led to descriptions of the depressive and hypo¬
manic types—the two basic temperaments in the kraepe-
linian scheme. Schneider's position was empirical and oper¬
ational; unlike Kraepelin, he did not genetically link these
two affective personalities to affective disorder.
Kretschmer,2 who subscribed to the kraepelinian concept
of a unity of affective psychoses, did not sharply demarcate
the affective temperaments. He defined a unitary cycloid or
cyclothymic type conforming to the following characteris¬
tics: (1) sociable, good-hearted, kind, and easygoing, (2)
elated, humorous, lively, and hot-tempered, (3) intro¬
verted, quiet, calm, serious, and gentle. It was postulated
that all cycloids met the first criterion, that predominantly
hypomanic cycloids more often behaved according to the
traits listed under item 2, and predominantly depressed
cycloids conformed to the third description. Kretschmer
hypothesized that the cycloid personality was the tempera¬
mental precursor of manic-depressive psychosis, just as the
schizoid type was related to schizophrenic psychosis. He
further postulated "all thinkable transitions and shadings
between health and disease,"2 ie, a continuum between
"healthy" cyclothymes, temperamentally "ill" cyclothymes
(the cycloids), and "psychotic" cyclothymes (manic-depres¬
sives).
The views of Sheldon et al96 were similar to Kretschmer's.
They claimed that most manic-depressives would have a
predominance of "viscerotonia" (endomorphy) and "somato-
tonia" (mesomorphy), with minimal features of "cerebro-
tonia" (ectomorphy). Combining some of the temperamen¬
tal characteristics of these constitutions, one can derive a
composite cycloid type characterized by alternatives be¬
tween (1) sloth and energetic drivenness; (2) sociophilia or
people-orientation social withdrawal; (3) aggressivity
under alcohol "friendly" drinking; (4) poor sleep habits
deep sleep; (5) extraversion introversion; and (6) need for
action need for people or solitude when troubled.
The thrust of these pioneering studies was that constitu¬
tional factors determined both the temperament and the
manifest affective psychosis. Although "hereditary taint"
was reported in many of these classic studies, their meth¬
odologies were retrospective and flawed by sampling bias
and the absence of control groups. To provide more vigorous
data on this issue, a prospective study24 was carried out at
the University of Tennessee with a mental health center
cohort that had never been hospitalized, but had serious,
chronic interpersonal difficulties. Of this sample, 10% met
the criteria for cyclothymia, ie, short-lived subsyndromal
biphasic mood swings (falling short of the definitions by
Feighner et al97 of depression and mania). Thus, what gave
the appearance of a characterologic disturbance proved to
be a phenomenologically milder form of bipolar illness. The
study also demonstrated heterogeneity within the cyclo¬
thymic realm; 50% were predominantly depressive, 10%
predominantly hypomanic, and 40% had a more equal
mixture of depressive and hypomanic swings. Further¬
more, the family histories, prospective course, and phar¬
macologie response to tricyclics in these cyclothymic pro-
bands were indistinguishable from those of classic bipolar I
manic-depressives, but were distinct from controls with
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00 0 0
Hyperthymia DOOuQdO
11 III I III! Ill
Cyclothymia
W
hiiminiii
Predominantly Depressed
Cyclothymia
lili lililí HI il
Subaffective Dysthymia Tricyclic
Continuum between hyperthymic, cyclothymic, and dysthymic dis¬
orders. White rectangles represent elevated periods; gray rec¬
tangles, depressed periods; in subaffective dysthymia elevated
period is in response to tricyclic challenge.
characterologic disorders. These observations provide sup¬
port for the kraepelinian hypothesis that the cyclothymic
personality is a genetically determined attenuated form,
and sometimes a precursor, of manic-depressive psychosis.
These findings have been replicated in another clinical
setting,98 and most importantly, in a carefully conducted
study of a nonpatient population.99 As expected, nonpatient
cyclothymics were, on the average, ten years younger than
cyclothymic patients.
In other Tennessee studies,23,27 a subgroup of thymolep-
tic-responsive dysthymic probands (who generally met the
DSM-III criteria for dysthymia and the schneiderian crite¬
ria95 for depressive personality) differed from a control
group of primary unipolar depressives in having signifi¬
cantly higher rates of familial bipolar illness and hypomanic
responses to tricyclic antidepressant therapy. Based on
such findings, a continuum between dysthymic and cy¬
clothymic temperaments was postulated100 (Figure). This is
concordant with Kretschmer's classic observations on the
depressive temperament "which can swing to great ex¬
tremes. The path over which it swings is a wide one ... it
does . .
swing towards the cheerful side, but not so often
.
and not so far, it lingers over in the unhappy direction."2*30'
In this framework, some forms of dysthymic disorder are
conceptualized as special instances of cyclothymia where
brief hypomanic swings are apparent only on tricyclic
challenge.100 Recently, Turner and King101 have also classi¬
fied dysthymia in the bipolar spectrum. Descriptive criteria
proposed elsewhere88 suggest that some personalities with
introverted-obsessoid features, who are habitually brood¬
ing, guilt-ridden, gloomy, pessimistic, self-denigrating,
anhedonic, and tend to oversleep—features reminiscent of
Schneider's depressive personality—might be suffering
from a genetically attenuated but lifelong form of affective
disorder. Careful evaluation of their lethargy will often
reveal psychomotor inertia that is worse in the morning.
Furthermore, while initially introverted, these patients
 sometimes appear extroverted and driven for short periods
of time (most typically in response to tricyclic challenge).
Temperament and Polarity of Illness
The studies reviewed thus far were conducted within the
framework of the kraepelinian unification82 of affective
temperaments and affective psychoses into a genetic con¬
tinuum wherein transitions are postulated to occur within
affective temperaments (as in the full-blown forms of the
illness) and between temperaments and psychosis. The
unipolar-bipolar dichotomy led to a corresponding dichoto-
mization of affective temperaments. To prove that unipolar
and bipolar psychoses were distinct entities, investigators
proceeded to demonstrate biologic and psychologic differ¬
ences between these groups. Many early studies focused on
temperamental differences. For instance, Leonhard and
associates102 showed a preponderance of subdepressive tem¬
peraments in the parents and offspring of unipolar pro-
bands, and hypomanic and cyclothymic temperaments in
those of bipolar probands. Perris' classification58 of unipolar
subjects as subvalid (bound to routine, easily tired, cau¬
tious, tense, and meticulous) and bipolar subjects as sub-
stable (naive, frank or open, and interested in their fellow
men) has already been commented on; however, it is uncer¬
tain if these traits are familial.
A recent study103 conducted at Washington University
attempted to adduce support for the dichotomous position.
On the 16-Personality Factor (16-PF) Questionnaire by Cat-
tell et al,104 unipolar probands had low scores on factor A
(loaded for cyclothymia) compared with controls; thus, the
hypothesis that unipolar probands would show a high
frequency of cyclothymia was not supported. Furthermore,
unipolar probands and "well" first-degree relatives had high
scores on factors that indicated they were shy (H), reserved
(A), moved by feelings (L), tense (Q4), and apprehensive and
guilt prone (0). All traits except the last are known to have
genetic determinants.104 In brief, the personality attributes
of the unipolar depressive were considered to be non-
cyclothymic, consisting of a constellation of largely geneti¬
cally determined traits on the 16-PF. However, these find¬
ings are far from definitive because personality measure¬
ment was undertaken at the end of a depressive episode,
which may bias the results in the direction of low cy¬
clothymia.
Gershon et al105 found no evidence for the dichotomous
position in their genetic investigation, which showed that
cyclothymic, but not depressive, personalities were over-
represented in the first-degree relatives of affective pro-
bands. By contrast, in the study by Angst et al,106 a higher
genetic loading for a spectrum of affective personality
disorders was shown in the bipolar group, supporting the
postulate of a bipolar genetic substrate for hyperthymic,
cyclothymic, and dysthymic temperaments discussed ear¬
lier.
In summary, current evidence tends to support the clas¬
sic notion that cyclothymic, hyperthymic, and, to some
extent dysthymic personalities represent genetically atten¬
uated expressions of the major affective disorders. There
may be little correspondence of type of affective tempera¬
ment to polarity of affective illness. The question of speci¬
ficity of personality to polarity of affective illness may have
arisen as a result of the methodologically questionable prac¬
tice of lumping together the large universe of nonen¬
dogenous depressions under the "unipolar" rubric. Any dif¬
ferences disclosed between bipolar and unipolar subjects
(the latter broadly defined) may simply reflect the differ¬
ences between affective personalities and a wide array of
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neurotic characterologic traits common to a large universe
of psychiatric dysfunction.
PERSONALITY AS AN ORTHOGONAL DIMENSION
TO AFFECTIVE DISORDER
Given the complexities in elucidating the relationship
between personality and affective disorders, the clinician
may simply elect to note both conditions on separate axes.11
This will assure that neither the affective nor the personal¬
ity disturbance are overlooked. This is indeed the position
endorsed by DSM-III.28
The complexities of the interphase between personality
and affective disorders are perhaps best exemplified by a
group of difficult patients who exhibit joint manifestations
of long-standing affective and flagrant personality disorder.
They are variously referred to as neurotic, charactero¬
logic,22 or chronic intermittent (minor)74 depressions. Typ¬
ically, the affective symptoms are mild or subsyndromal and
pursue an intermittent chronic course, although full syn-
dromal episodes are often superimposed on this low-grade
pattern22; in many of these patients personality distur¬
bances may be more visible and take the form of manip-
ulativeness, temper tantrums, impulsivity, episodic prom¬
iscuity, repeated conjugal failure, drug-seeking behavior,
dilettantism, and suicide gestures or even attempts. Many
such patients suffer from dysthymic,22 cyclothymic,24 rapid
cycling, atypical, or bipolar II disorders5 (axis I), but they
simultaneously meet the DSM-III criteria for borderline
and related personality disorders (axis II).28 Although such
a biaxial classification is a reasonable approach to the
diagnostic dilemmas presented by these patients, it does
not resolve the question of which psychopathology is pri¬
mary.88 Prospective followup studies suggest that the af¬
fective component is often primary.5,10,2124 Some patients
considered to have borderline personality because of an "un¬
stable sense of self" may acquire "ego stability" on mainte¬
nance therapy with lithium carbonate.5 In other adult
patients with joint characterologic and chronic affective
disturbances, interpersonal maladjustment persists de¬
spite energetic chemotherapy.23 In these patients, personal¬
ity disorder may have developmental roots and can be
considered to be truly orthogonal to the affective axis."
Recent limited evidence from thymoleptic treatment of
children with both chronic depressive and conduct disor¬
ders indicates that both conditions are controlled by such
treatment,90,91 and raises the hope of prevention of the long-
term personality disturbance seen in early-onset affective
disorders.
The belief that long-term psychotherapy may prevent
further affective episodes or a chronic affective denouement
is based on the premise that characterologic disturbances
are of primary etiologic significance in affective disorders.3
The evidence reviewed in this article suggests that more
may be gained by focusing psychotherapy on the social
maladjustments that occur in close temporal contiguity
with affective episodes. Thus, brief, practical psychothera-
peutic approaches aimed at conjugal, familial, financial, and
vocational matters should prove useful in decreasing post-
depressive (and postmanic) personality disturbances before
they crystallize into chronic maladaptive habits. For exam¬
ple, by promoting improved communication between
spouses, psychotherapy may help to resolve interpersonal
conflicts that may hinder recovery from depressive epi¬
sodes.85 It is reasonable to suggest that such pragmatic
approaches could enhance or consolidate the therapeutic
gains achieved through pharmacologie symptom control.85,86
An important goal of psychologic treatment is to protect the
 patient (and significant others) from rash and irreversible
decisions in major life areas (eg, divorce, inheritance,
investments, or geographic moves) that can be easily influ¬
enced, even dictated, by pathologic mood change. Whether
psychotherapy aimed at modifying certain personality op¬
erations like poor social skills or maladaptive cognitive
styles can prevent de novo affective episodes is a research
challenge for the future.
FUTURE RESEARCH DIRECTIONS
It is evident from the foregoing presentation that our
understanding of the relationship between personality and
affective disorder has been hampered by méthodologie
limitations. Klein107 has suggested that recent advances in
pathophysiologic understanding of psychiatric disorders
have involved a shift from naturalistic clinical observation
to controlled experimental approaches. Such approaches,
based on modern advances in behavioral genetics, psychom-
etry, pharmacologie dissection, and other biological mark¬
ers, are becoming increasingly relevant to the area of per¬
sonality and affective illness.21 These approaches should
help in reversing the méthodologie shortcomings cited in
this article.
Heterogeneity of Affective Disorders
Unless specific validated subtypes of affective disorder
are examined, future work is unlikely to reveal replicable
personality findings. In particular, it would be fruitful to
examine personality in affective subtypes defined by famil¬
ial-genetic history, or by such biologic markers as the
dexamethasone suppression and REM latency tests.108,109
Retrospective Assessment of Personality
Assessments have generally been made after the onset of
the illness, thereby confounding effects of illness on person¬
ality and posing the most serious méthodologie problem in
this area. Personality assessment during an affective epi¬
sode is obviously unsatisfactory because of the difficulty of
separating personality attributes from clinical symptoms,
and the possibility that the affective state may impart a
transient affective coloring to the person, or color percep¬
tions of past personality operations. However, even when
patients are examined during an episode-free asympto¬
matic period or an interepisodic period, one must consider
the possibility that past affective episodes themselves may
have altered personality. For example, low self-confidence,
interpersonal dependency, and helplessness, often men¬
tioned as possible predisposing traits, could conceivably
result from repeated episodes of depression. Indeed, such
traits may easily develop in the context of any illness that is
intermittently or chronically incapacitating and requires
surveillance or support by family members.110
It has been suggested that scores similar to those of
asymptomatic periods might be obtained by instructing
patients to disregard their current state of illness and to
respond according to their "usual selves."50 Contrasting
personality attributes after first affective episodes with
those following multiple episodes, and obtaining informa¬
tion about premorbid personality from significant others
(spouse, parent, or sibling) who have lived with the patient
for long periods before affective breakdown, are reasonable
but infrequently used approaches. Another useful strategy
is to record changes in personality scores from symptomatic
to more or less asymptomatic periods63; only those personal¬
ity attributes during the asymptomatic period that are sig¬
nificantly deviant from those of population controls would
conceivably reflect pathology in the premorbid personality.
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The Assessment of Personality Types
Conventional personality types have been traditionally
considered unreliable because of criterion variance.1" In¬
vestigators have attempted to bypass this thorny problem
by recourse to more reliable paper-and-pencil instruments
of personality measurement such as the EPI,™ Leyton,51
Mark-Nyman,56 and Lazare-Klerman-Armor112 inventories.
Another approach might be to use the schneiderian typol¬
ogy,95 which has high interrater reliability for empirically
defined asthénie, explosive, depressive, and affectionless
personalities."3 Unfortunately, of these personality types,
only the depressive is familiar to a general clinical reader¬
ship.
Even when reliable and valid measures of personality
attributes in affective disorders are obtained, there re¬
mains the question of elucidating their relevance to the
pathogenesis of affective episodes. Teasing apart epiphe-
nomenal personality correlates from causal antecedents is
particularly difficult. Ideally, personality should be as¬
sessed before affective episodes have occurred. One strat¬
egy is to study high-risk groups, such as the offspring of
affectively ill patients, or certain personality types (de¬
pendent, compulsive, dysthymic, or cyclothymic) consid¬
ered prone to affective episodes, before they have suffered
syndromal affective breakdowns. A related approach is to
compare the personalities of affective probands and their
relatives (with no history of affective episode).
CONCLUSIONS
Given the range of méthodologie difficulties reviewed in
this article, it is understandable that definitive findings
relating personality to affective disorders have not yet
emerged. The available data permit the following tentative
conclusions.
1. Bipolar affective psychoses often arise from the soil of
extraverted, cyclothymic, and related dysthymic tempera¬
mental disorders; a driven, work-oriented obsessoid quality
is often present in such temperaments. Those recurrent
unipolar depressions that are closely linked to bipolar
illness may also arise from the same affective temperamen¬
tal foundations.
2. Of all the personality attributes hypothesized to pre¬
dispose to nonbipolar conditions, introversion appears to be
the trait for which there is the strongest evidence. Other
attributes such as dependency and negative self-attribu¬
tions may largely reflect state effects on the postdepressive
personality.
3. Although interpersonal difficulties following affective
episodes tend to be short-lived, in many patients post-
depressive personality disturbances persist for many
years. It is conceivable that these disturbances represent
accentuation of premorbid traits, or the incorporation of
episode-related affective experiences into the interepisodic
phase of the illness.
Future research may reveal more complex links whereby
both personality and affective illness emerge as part of a
multifactorial continuum, including familial-genetic load¬
ing, developmental vicissitudes, sociocultural background,
sex effects, and life events. Although there are theoretical
models"4,115 that encompass such variables, from a clinical
standpoint they can be considered unwieldy mathematical
exercises at this time. Obviously, much work lies ahead in
designing the appropriate experiments to test the hypoth¬
eses reviewed in this report. For instance, studies that
divide unipolar depressions on the basis of endogeneity,
recurrence, familial criteria, and selected biologic markers
may help to determine whether different personality con-
 stellations predispose to specific subtypes of unipolar ill¬
ness. More generally, research efforts should (1) take the
heterogeneity of affective disorders into consideration, (2)
use reliable personality assessments that are clinically
cogent, (3) be designed in such a way as to permit timing of
personality assessments most appropriate for the hypoth¬
eses posed, and (4) combine self-assessment, psychiatric
evaluation and observations on personality by significant
others such as parents, classmates, and co-workers. Al¬
though naturalistic observations have generated interest¬
ing hypotheses linking personality to affective disorders,
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