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ScienceDirect Comprehensive Psychiatry 55 (2014) 511 – 517 www.elsevier.com/locate/comppsych
The impact of personality on quality of life and disease activity in patients with Behcet’s disease: a pilot study Inci Meltem Atay a,⁎, Ijlal Erturan b, 1 , Arif Demirdas a, 2 , Gozde Bacık Yaman a, 3 , Vedat Ali Yürekli c, 4 a
b
Suleyman Demirel University Department of Psychiatry, Isparta, Turkey Suleyman Demirel University Department of Dermatology, Isparta, Turkey c Suleyman Demirel University Department of Neurology, Isparta, Turkey
Abstract Background: The aim of this study was to examine the personality characteristics of patients with Behcet’s Disease (BD) using the Temperament and Character Inventory (TCI) compared with healthy control subjects and to investigate the relationship between the temperament and character properties and quality of life, disease activity, depression and anxiety in Behcet’s patients. Methods: A total of 46 BD patients and 40 healthy subjects were included in the study. All patients and controls were determined using the TCI, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Clinical Version for Axis I disorders (SCIDCV), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Quality of life (QOL) Instrument for Skin Disorders and Behcet Disease Current Activity Form (BDCAF). Results: BD patients demonstrated significantly lower Reward Dependence than healthy controls. Among the subscales; Explarotory Excitability, Shyness with Strangers, Attachment, Spiritual Acceptance were lower and Self-Acceptance was higher in patients compared to control subjects. Decreased quality of life and increased disease activity of the patients were correlated with increased anxiety and depression. Responsibility, Self-Forgetfulness and Transpersonal Identification were associated with quality of life while Responsibility was the major factor effecting QOL. Disease activity was not found related with TCI properties. Conclusion: Temperament and Character traits of BD patients were different from healthy group that might be due to many factors like genetics, biological or socio-cultural differences. BD patients were demonstrated as materialistic, self-contained, self-confident, cold, detached, and reserved although they are not shy. Considering the different personality traits of BD patients in psychotherapeutic approaches, may have a positive impact on QOL and comorbid major depressive disorder. © 2014 Elsevier Inc. All rights reserved.
1. Introduction BD is a chronic, inflammatory, multisystemic disorder characterized by recurrent oral aphthous ulcers, genital ulcers and skin lesions. BD is mostly common in
⁎ Corresponding author. Tel.: +90 246 2119172; fax: +90 246 2112830. E-mail addresses: [email protected] (I.M. Atay), [email protected] (I. Erturan), [email protected] (A. Demirdas), [email protected] (G.B. Yaman), [email protected] (V.A. Yürekli). 1 Tel.: +90 505 2835269. 2 Tel.: +90 533 6599876. 3 Tel.: +90 505 3912380. 4 Tel.: +90 505 5788887. 0010-440X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.11.008
Mediterranean population [1]. It’s known that the chronicity of the disease, neurological and other system involvements, treatments and the disabilities caused by the disease affect the patient’s quality of life, life satisfaction and may also be associated with a psychiatric disorder mostly like depression and anxiety disorders [2–4]. The studies about the psychiatric effects on disease activity and quality of life are mostly focused on depression and anxiety [4,5]. Although personality is one of the major factors determining the reasons and prevention of psychiatric comorbidity, there is no study about the personality traits associated with depression, anxiety, disease activity and the quality of life in Behcet’s patients. Cloninger's psychobiological model of personality has been mostly used to investigate the cases with chronic
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Table 1 Descriptive and clinical characteristics of cases and controls.
Sex F/M Age Duration of Behçet’s disease, years, mean ± SD Disease activity, mean ± SD Dermatological Quality of Life (QOL), mean rank a b c
Cases (n = 46)
Controls (n = 40)
p
27(%58.7)/19 (%41.3) 36.46 ± 11.22 8.13 ± 7.32 3,98 ± 2.13 55.82
25(%62.5)/15 (%37.5) 33.36 ± 10.24 – – 17.95
0.657 a 0.214 b – – 0.000 c
Chi-square Test. Independent Sample-t Test. Mann–Whitney U Test.
disorders or dermatologic diseases like psoriasis, primary focal hyperhidrosis and acne vulgaris [6–9]. According to Cloninger’s psychobiological model, personality is a complex system consisting of different psychobiological dimensions of temperament and character. Temperament refers to automatic emotions and responses thought to be moderately heritable and genetically based, whereas character is also heritable but is responsive to social learning and maturation by norm-favoring [9,10]. Cloninger and colleagues identified four temperament dimensions as novelty seeking, harm avoidance, reward dependence and persistence and three character dimensions as self-directedness, cooperativeness and self-transcendence [11]. In this study, it was aimed to compare the temperament and character properties of Behcet’s patients and healthy controls based on Cloninger’s psychobiological personality model, and to investigate the relationship between the temperament and character traits and quality of life, disease activity, depression and anxiety in Behcet’s patients.
sion Inventory (BDI) and Beck Anxiety Inventory (BAI) [14–21]. A written informed consent was given to all patients and controls who accepted to participate to the study. 2.1. Measurement tools 2.1.1. Temperament and Character Inventory (TCI) Temperament and Character Inventory is a self-assesment tool consists of 240 items rated as “true” or “false”. Temperament has four dimensions, defined as Novelty Seeking(NS), Harm Avoidence(HA), Reward Dependence (RD) and Persistence (P). Character has three dimensions as Self-Directedness (SD), Cooperativeness (C), and SelfTranscendence (ST). Kose et al. and Arkar conducted Turkish reliability and validity study of the scale [15–17]. 2.1.2. Beck Depression Inventory (BDI) Beck Depression Inventory (BDI) is a self-report inventory that measures the severity of depression [18]. BDI includes 21 items scored between 0 and 3.The Turkish version was validated by Hisli N [19].
2. Methods A total of 46 Behcet’s patients and age, sex and educational level matched 40 healthy controls over the age of 18 were included in the study. The study included patients who were admitted to the outpatient clinic of the dermatology department. Patients with known other dermatological diseases, systemic disorders (ie, diabetes mellitus, hypertension), mental retardation, serious psychiatric disorders including demantia, obsessive–compulsive disorder, psychotic disorders and patients with neurologic involvement were excluded from the study. The diagnosis of BD was performed according to the international study group criteria. BD activity was calculated according to the Behcet Disease Current Activity Form (BDCAF) [12]. Quality of Life (QOL) instrument developed by Gurel et al. for Turkish people with skin diseases was used to determine the quality of life [13]. The psychiatric evaluations of the patients were performed by the same psychiatrist. All patients and controls were determined using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I disorders, Turkish version of the Temperament and Character Inventory (TCI), Beck Depres-
2.1.3. Beck Anxiety Inventory (BAI) The BAI is a self-report inventory consisting of 21-items scored between 0 and 3 that measures the frequency of physiological and other symptoms of anxiety experienced Table 2 Comparison of the Temperament and Character Inventory in cases and controls.
Novelty seeking Harm avoidance Reward dependence Persistence Self-directedness Cooperativeness Self-transcendence
Group
Mean ± SD
p value a
Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls
15.19 17.03 18.43 20.57 12.82 14.87 5.02 4.91 28.17 26.09 28.63 27.94 17.24 18.91
0.076
Bold data signifies pb 0.05. a Independent Sample T Test.
± ± ± ± ± ± ± ± ± ± ± ± ± ±
4.53 4.38 7.08 6.86 3.16 2.63 1.93 1.81 6.86 6.58 6.77 5.44 5.00 5.13
0.183 0.003 0.793 0.180 0.629 0.151
I.M. Atay et al. / Comprehensive Psychiatry 55 (2014) 511–517 Table 3 Comparison of the subscales of Temperament and Character Inventory in cases and controls.
Exploratory excitability (NS1) Shyness (HA3) Attachment (RD3) Self-acceptance (SD4) Spiritual Acceptance (ST3) a
Group
Mean ± SD
p value a
Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls
4.72 5.70 3.48 4.51 3.71 4.81 6.39 4.97 6.60 7.70
0.025
± ± ± ± ± ± ± ± ± ±
1.85 1.93 2.27 1.99 1.65 1.74 2.44 2.49 2.27 2.44
0.038 0.006 0.014 0.045
Independent Sample T Test.
during the previous week [20]. The Turkish version was validated by Ulusoy M et al. [21]. 2.2. Data analysis The results were analyzed by the SPSS package program version 15.0 (SPSS Inc., Chicago, IL, USA). Variables were expressed with mean ± standart deviation. Continuous variables between the two groups were compared with Independent-t test or Mann–Whitney U test according to the normal distribution of the variables. Chi-square test was performed for qualitative variables. The relationship between the parameters was assessed by using Pearson’s correlation and analysis. Multiple linear regression analysis was used to assess independent associations between the variables. The variance inflation factor (VIF) for independent variables was b5 in collinearity statistics. No evidence was found that would effect the linear and unbiased estimations which were related with error terms. The calculated p value b 0.05 was considered statistically significant.
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In the analysis of subscales of TCI; the mean scores of Explarotory Excitability, Shyness with Strangers, Attachment, and Spiritual Acceptance were significantly lower in Behcet’s patients compared to healthy controls, whereas the mean score of Self-Acceptance was higher in patients (Table 3). 3.3. The results of the correlations Persistance and Cooperativeness were positively correlated with age. Self-directedness was negatively correlated with Beck Anxiety scores. Self-Transcendence was positively correlated with Beck Anxiety and QOL (Table 4). Purposefulness, Helpfulness, Compassion, and Transpersonal identification were positively correlated with age. Disorderliness was negatively correlated with age. All those parameters were not correlated in controls except for Helpfulness. Responsibility was negatively correlated with Beck Anxiety scores. Self-Forgetfulness was positively correlated with QOL. Responsibility was negatively correlated with QOL. Disorderliness was negatively correlated with the duration of the disease (Table 5). 3.4. Correlations of BAI and BDI scores with QOL, disease activity and the duration of the disease BAI was positively correlated with QOL (r:0.677; p:0.000) and disease activity (r:366; p:0.012). BDI was positively correlated with QOL (r:0.676; p:0.000), disease activity (r:0.302; p:0.041) and the duration of the disease (r:0.309; p:0.037). 3.5. Multiple linear regression analysis of temperament and character ınventory properties associated with QOL Multiple linear regression analysis indicated that Responsibility was the major predictive factor of QOL (Table 6). 4. Discussion
3. Results 3.1. Clinical characteristics of the study subjects A total of 46 patients with BD diagnosed for more than 6 months participated in the study. Age, gender and educational level matched 40 healthy controls were enrolled in the study. There was no significant difference between the two groups in terms of gender, age and educational level. Descriptive and clinical characteristics of both case and control gropus are shown in Table 1. The score of QOL was higher in Behcet’s group than controls (p b 0.001). 3.2. The results of the temperament and character ınventory The mean score of Reward Dependence was lower in Behcet’s patients than healthy controls (Table 2). Reward Dependence scores were still significantly different from the healthy controls after controlling depression (t:3.126; p:0.003).
The present study aimed to determine the personality traits of Behcet’s patients compared with healthy controls using the TCI and to investigate whether personality related to quality of life and disease activity with the disease duration, depressive and anxiety symptoms in Behcet’s disease.
Table 4 Correlation coefficients between Temperament and Character Inventory and age, BAI, QOL and the duration of the disease.
Persistence Cooperativeness Self-Directedness Self-Transcendence ⁎ p b 0.05. ⁎⁎ p b 0.01.
Age (r-value)
BAI (r-value)
QOL (r-value)
⁎0.303 ⁎0.297 – –
– – ⁎−0.322 ⁎0.294
– – – ⁎⁎0.383
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Table 5 Correlation coefficients between the subscales of Temperament and Character Inventory and age, BAI, QOL and the duration of the disease.
Disorderliness Purposefulness Helpfulness Compassion vs revenge Transpersonal Identification Responsibility Self-Forgetfulness
Age (r-value)
BAI (r-value)
QOL (r-value)
Duration of the disease (r-value)
−0.450⁎⁎ 0.306⁎ 0.300⁎ 0.331⁎
– – – –
– – – –
−0.374⁎ – – –
0.397⁎⁎
–
–
–
– –
−0.322⁎
−0.370⁎ 0.315⁎
– –
⁎ p b 0.05. ⁎⁎ p b 0.01.
4.1. Personality traits of Behcet’s patients It’s known that BD is a chronic immunoinflammatory disease with periods of exacerbation and remission and may be induced by stress–immune system interaction [22,23]. The effect of stress in the relapse and remission cycle of BD was demonstrated in early studies. Anxiety and depression were found as two important indicators of stress [22,24]. It has been shown that personality traits play an important role in stress management, depression and anxiety [11]. Thus, we mainly studied the personality traits of BD patients and compared our results with healthy controls and other reports of chronic immunologic and dermatological disorders. Although several studies about personality traits and their effects on different chronic disorders like multiple sclerosis (MS), sarcoidosis, epilepsy, chronic fatigue syndrome, asthma and diabetes mellitus patients were performed before, there have been no previous reports about the personality traits of Behcet’s patients assessed by TCI or other methods [25–30]. Only a study conducted by Koptagel-Ilal et al., suggested that patients with BD had pathological personality structures, including weak ego, regressive tendencies, disturbed body image, high anxiety, difficulties in social adaptation, and coping with emotions [31]. Our results demonstrated that BD patients had lower Exploratory Excitability scores as a subdimension of Novelty-Seeking compared with healthy controls and that in terms of Cloninger’s personality traits patients with BD show less excitable reactions to a pleasant stimuli and have diminished positive affect and exploratory behavior [11]. Svrakic et al., reported that lower scorers of Exploratory Excitability were reserved [32]. They are resistant or slow to engage in new ideas and activities. These people are rarely bored and thus tend to stick with familiar routines even if there are new and better ways to do the same thing [33,15]. Nevertheless, shyness with strangers’ sub dimension of Harm Avoidance was lower in BD patients that we can assume BD patients are not shy in an unfamiliar situation. Other sub dimensions of Harm Avoidance and Novelty
Seeking scores were not different from healthy controls incompatible with the results of other psychosomatic disorders or MS. Ustun et al., reported that MS patients had higher harm avoidance and impulsiveness, and were pessimistic, avoidant and easily fatigued [34]. Most of the studies about chronic disorders like chronic tension type headache, anxiety disorders, depression, myotonic dystrophy, chronic fatigue syndrome, psoriasis and fibromyalgia demonstrated higher Harm Avoidance scores [6,28,35–38]. Although some studies had controversial results, Harm Avoidance scores were also found higher in most of the somatization disorders [39,40]. BD is a chronic disease but, our findings were not similar for Harm Avoidance scores with those chronic disorders which might be due to different etiopathogenetic mechanisms in BD. Besides our study group did not include patients with debilitating neurological complications and most of our patients were not depressive which might affect the results. Another different dimension in temperament was Reward Dependence. We found lower scores of Reward Dependence in BD patients than healthy controls. Reward Dependence describes the maintenance of behavior in response to cues of social reward. Low scores of Reward Dependence show that BD patients may have difficulties in social attachment which may result in relationship problems and susceptibility to psychiatric disorders like depression or adjustment problems. Low scorers on the Attachment subscale manifest more or less pronounced detachment and disinterest in social relationships. They prefer privacy over intimacy and are thus often described as self-contained. These individuals typically do not share their intimate feelings with others. They impress others as alienated, detached who are usually indifferent to rejection and insults [15,33]. Svrakic et al. regarded the lower scorers of attachment as cold personalities [32]. Fruyt et al. concluded that low Reward Dependence was related to introversion [41]. Since, introversion is a complex factor with loadings from high Harm Avoidance and low Reward Dependence, our findings showed that BD patients were just low in Reward Dependence indicating cold and detached personality traits. In accordance with our findings, Kim et al. found lower scores in Reward Dependence for atopic dermatitis patients and suggested that it might be linked to
Table 6 Multiple linear regression analyses associated with QOL in Behcet’s patients. Independent variables
Responsibility Self-forgetfulness Transpersonal identification R 2(multiple coefficient of determination)
Standart regression coefficients (β) QOL −0.304⁎ 0.151 0.162 0.206⁎
VIF values (Responsibility:1.088; Self-forgetfulness:1.418; Transpersonal identification:1.317). ⁎ p b 0.05.
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depressive symptoms [42]. But in our study Reward Dependence scores were still lower after controlling depressive symptoms. Therefore attachment problems should be considered carefully in BD patients during psychotherapeutic approaches. It’s known that temperament traits were found associated with neurophysiological circuits and neurotransmitter systems. Reward Dependence was shown associated with noradrenergic activity in the central nervous system [43]. Our study revealed remarkable results for Reward Dependence. In literature there are a limited number of researches about noradrenergic system in BD. Aksoyek et al. reported that BD patients had increased sympathetic and decreased parasympathetic modulation and suggested BD patients might have an asymptomatic autonomic nervous system dysfunction [44]. Tellioglu and Robertson indicated an autonomic dysfunction accompanied by abnormal catecholamine levels in a BD patient and suggested a contribution of an immunological damage to the components of neural pathways in the pathogenesis of the autonomic involvement [45]. Also in a recent case report, a BD patient with Sympathetic storms which were characterized by hyperactivity of autonomic functions had high levels of catecholamine and IL-8 in cerebrospinal fluid. The patient was treated with corticosteroids and intravenous cyclophosphamide. The concentrations of NE and IL-8 were decreased to normal levels after the improvement of the symptoms [46]. Our result for Reward Dependence is also pointing out norepinephrine disturbance that further studies about noradrenergic neuronal pathways, might be helpful in order to clarify the etiology, immunological and genetic patterns in BD patients. In character dimensions, the Self-Acceptance scores were higher in patients. This result was incompatible with the result of Ustun et al. who found lower scores in MS patients. Although there are many factors effecting Self-Acceptance, this result may be due to the clinical differences of MS that may be more destructive than BD and due to the MS study group which involved patients with fatigue [34]. The last character sub-dimension different from healthy controls was Spiritual Acceptance. We found lower scores in BD patients than controls and lower scores represent materialistic personalities as Cloninger et al. indicated before. These individuals are generally unwilling to accept things that cannot be scientifically explained. The disadvantage of lower scores for Spiritual Acceptance is those individuals may have difficulties when confronted by inevitable death, suffering, or unjust punishments [11,15]. 4.2. The relations of temperament and character properties with quality of life, disease activity, disease duration, anxiety and depression in BD We found that Responsibility which is a sub dimension of Self-Directedness is decreasing with the decrease of quality of life while Self-Transcendence and Self-Forget-
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fulness are increasing in BD patients. In other words lower quality of life in Behcet’s patients may cause some characteristic differences as they are less responsible and more intuitive. Besides our study demonstrated that patients are more stoical, persistent, purposeful, compassionate and acquiescent with the increase of age and those results were different from the healthy controls. We suggest that those differences in characteristics might be due to the psychosocial effects of BD. Disease activity was associated with anxiety and depression scores. But the temperament and character properties were not related with disease activity. In recent studies anxiety and depression were found to be associated with disease activity and quality of life in BD. Uguz et al. reported that major depression had a negative impact on QOL of BD patients and that QOL is negatively correlated with the severity of depressive symptoms [47]. Another study revealed positive correlations between BDI scores and patient's impression of disease activity in BD patients [5]. Our findings were concurrent with literature that depression and anxiety scores were positively correlated with the disease activity, duration of the disease and the QOL scores. In regression analysis, Responsibility, Self-Forgetfulness and Transpersonal Identification were negatively associated and Self-Transcendence was positively associated with quality of life and Responsibility was the major predictive factor for quality of life in Behcet’s patients. Celikel et al. reported lower Responsibility scores in major depressive disorder patients [48]. Our results were similar with those that showed that lower quality of life was correlated with depression and was related with responsibility subdimension in BD patients as well. Yoda et al. also showed a positive correlation between HbA1C and Responsibility scores for Type 2 diabetic patients [30]. There are several limitations to this study. The personality assessment was based on self-reporting questionnaire and was not objective. Also some of the patients did not accept to be involved our study due to the duration of the scale application which limited our sample size. Nevertheless, assessing the Temperament and Character traits of BD patients for the first time is the major strength of our study. In conclusion, this study suggests that BD patients have distinctive temperament such as Reward Dependence dimension compared with healthy controls. Patients with BD seem to be materialistic, self-contained, self-confident, cold, detached and reserved although they are not shy. These temperament and character differences may be due to many effects like genetics, socio-cultural influences or even due to a common neurologic pathway for BD and personality traits. Decreased quality of life and increased disease activity of the patients were correlated with increased anxiety and depression. Responsibility, Self-Forgetfulness, Transpersonal Identification and Self-Transcendence were associated with quality of life. Responsibility subdimension was the major factor effecting quality of life of BD patients which might be linked to depressive symptoms. In the future, longitudinal
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ScienceDirect Comprehensive Psychiatry 55 (2014) 511 – 517 www.elsevier.com/locate/comppsych
The impact of personality on quality of life and disease activity in patients with Behcet’s disease: a pilot study Inci Meltem Atay a,⁎, Ijlal Erturan b, 1 , Arif Demirdas a, 2 , Gozde Bacık Yaman a, 3 , Vedat Ali Yürekli c, 4 a
b
Suleyman Demirel University Department of Psychiatry, Isparta, Turkey Suleyman Demirel University Department of Dermatology, Isparta, Turkey c Suleyman Demirel University Department of Neurology, Isparta, Turkey
Abstract Background: The aim of this study was to examine the personality characteristics of patients with Behcet’s Disease (BD) using the Temperament and Character Inventory (TCI) compared with healthy control subjects and to investigate the relationship between the temperament and character properties and quality of life, disease activity, depression and anxiety in Behcet’s patients. Methods: A total of 46 BD patients and 40 healthy subjects were included in the study. All patients and controls were determined using the TCI, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Clinical Version for Axis I disorders (SCIDCV), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Quality of life (QOL) Instrument for Skin Disorders and Behcet Disease Current Activity Form (BDCAF). Results: BD patients demonstrated significantly lower Reward Dependence than healthy controls. Among the subscales; Explarotory Excitability, Shyness with Strangers, Attachment, Spiritual Acceptance were lower and Self-Acceptance was higher in patients compared to control subjects. Decreased quality of life and increased disease activity of the patients were correlated with increased anxiety and depression. Responsibility, Self-Forgetfulness and Transpersonal Identification were associated with quality of life while Responsibility was the major factor effecting QOL. Disease activity was not found related with TCI properties. Conclusion: Temperament and Character traits of BD patients were different from healthy group that might be due to many factors like genetics, biological or socio-cultural differences. BD patients were demonstrated as materialistic, self-contained, self-confident, cold, detached, and reserved although they are not shy. Considering the different personality traits of BD patients in psychotherapeutic approaches, may have a positive impact on QOL and comorbid major depressive disorder. © 2014 Elsevier Inc. All rights reserved.
1. Introduction BD is a chronic, inflammatory, multisystemic disorder characterized by recurrent oral aphthous ulcers, genital ulcers and skin lesions. BD is mostly common in
⁎ Corresponding author. Tel.: +90 246 2119172; fax: +90 246 2112830. E-mail addresses: [email protected] (I.M. Atay), [email protected] (I. Erturan), [email protected] (A. Demirdas), [email protected] (G.B. Yaman), [email protected] (V.A. Yürekli). 1 Tel.: +90 505 2835269. 2 Tel.: +90 533 6599876. 3 Tel.: +90 505 3912380. 4 Tel.: +90 505 5788887. 0010-440X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.11.008
Mediterranean population [1]. It’s known that the chronicity of the disease, neurological and other system involvements, treatments and the disabilities caused by the disease affect the patient’s quality of life, life satisfaction and may also be associated with a psychiatric disorder mostly like depression and anxiety disorders [2–4]. The studies about the psychiatric effects on disease activity and quality of life are mostly focused on depression and anxiety [4,5]. Although personality is one of the major factors determining the reasons and prevention of psychiatric comorbidity, there is no study about the personality traits associated with depression, anxiety, disease activity and the quality of life in Behcet’s patients. Cloninger's psychobiological model of personality has been mostly used to investigate the cases with chronic
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Table 1 Descriptive and clinical characteristics of cases and controls.
Sex F/M Age Duration of Behçet’s disease, years, mean ± SD Disease activity, mean ± SD Dermatological Quality of Life (QOL), mean rank a b c
Cases (n = 46)
Controls (n = 40)
p
27(%58.7)/19 (%41.3) 36.46 ± 11.22 8.13 ± 7.32 3,98 ± 2.13 55.82
25(%62.5)/15 (%37.5) 33.36 ± 10.24 – – 17.95
0.657 a 0.214 b – – 0.000 c
Chi-square Test. Independent Sample-t Test. Mann–Whitney U Test.
disorders or dermatologic diseases like psoriasis, primary focal hyperhidrosis and acne vulgaris [6–9]. According to Cloninger’s psychobiological model, personality is a complex system consisting of different psychobiological dimensions of temperament and character. Temperament refers to automatic emotions and responses thought to be moderately heritable and genetically based, whereas character is also heritable but is responsive to social learning and maturation by norm-favoring [9,10]. Cloninger and colleagues identified four temperament dimensions as novelty seeking, harm avoidance, reward dependence and persistence and three character dimensions as self-directedness, cooperativeness and self-transcendence [11]. In this study, it was aimed to compare the temperament and character properties of Behcet’s patients and healthy controls based on Cloninger’s psychobiological personality model, and to investigate the relationship between the temperament and character traits and quality of life, disease activity, depression and anxiety in Behcet’s patients.
sion Inventory (BDI) and Beck Anxiety Inventory (BAI) [14–21]. A written informed consent was given to all patients and controls who accepted to participate to the study. 2.1. Measurement tools 2.1.1. Temperament and Character Inventory (TCI) Temperament and Character Inventory is a self-assesment tool consists of 240 items rated as “true” or “false”. Temperament has four dimensions, defined as Novelty Seeking(NS), Harm Avoidence(HA), Reward Dependence (RD) and Persistence (P). Character has three dimensions as Self-Directedness (SD), Cooperativeness (C), and SelfTranscendence (ST). Kose et al. and Arkar conducted Turkish reliability and validity study of the scale [15–17]. 2.1.2. Beck Depression Inventory (BDI) Beck Depression Inventory (BDI) is a self-report inventory that measures the severity of depression [18]. BDI includes 21 items scored between 0 and 3.The Turkish version was validated by Hisli N [19].
2. Methods A total of 46 Behcet’s patients and age, sex and educational level matched 40 healthy controls over the age of 18 were included in the study. The study included patients who were admitted to the outpatient clinic of the dermatology department. Patients with known other dermatological diseases, systemic disorders (ie, diabetes mellitus, hypertension), mental retardation, serious psychiatric disorders including demantia, obsessive–compulsive disorder, psychotic disorders and patients with neurologic involvement were excluded from the study. The diagnosis of BD was performed according to the international study group criteria. BD activity was calculated according to the Behcet Disease Current Activity Form (BDCAF) [12]. Quality of Life (QOL) instrument developed by Gurel et al. for Turkish people with skin diseases was used to determine the quality of life [13]. The psychiatric evaluations of the patients were performed by the same psychiatrist. All patients and controls were determined using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I disorders, Turkish version of the Temperament and Character Inventory (TCI), Beck Depres-
2.1.3. Beck Anxiety Inventory (BAI) The BAI is a self-report inventory consisting of 21-items scored between 0 and 3 that measures the frequency of physiological and other symptoms of anxiety experienced Table 2 Comparison of the Temperament and Character Inventory in cases and controls.
Novelty seeking Harm avoidance Reward dependence Persistence Self-directedness Cooperativeness Self-transcendence
Group
Mean ± SD
p value a
Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls
15.19 17.03 18.43 20.57 12.82 14.87 5.02 4.91 28.17 26.09 28.63 27.94 17.24 18.91
0.076
Bold data signifies pb 0.05. a Independent Sample T Test.
± ± ± ± ± ± ± ± ± ± ± ± ± ±
4.53 4.38 7.08 6.86 3.16 2.63 1.93 1.81 6.86 6.58 6.77 5.44 5.00 5.13
0.183 0.003 0.793 0.180 0.629 0.151
I.M. Atay et al. / Comprehensive Psychiatry 55 (2014) 511–517 Table 3 Comparison of the subscales of Temperament and Character Inventory in cases and controls.
Exploratory excitability (NS1) Shyness (HA3) Attachment (RD3) Self-acceptance (SD4) Spiritual Acceptance (ST3) a
Group
Mean ± SD
p value a
Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls
4.72 5.70 3.48 4.51 3.71 4.81 6.39 4.97 6.60 7.70
0.025
± ± ± ± ± ± ± ± ± ±
1.85 1.93 2.27 1.99 1.65 1.74 2.44 2.49 2.27 2.44
0.038 0.006 0.014 0.045
Independent Sample T Test.
during the previous week [20]. The Turkish version was validated by Ulusoy M et al. [21]. 2.2. Data analysis The results were analyzed by the SPSS package program version 15.0 (SPSS Inc., Chicago, IL, USA). Variables were expressed with mean ± standart deviation. Continuous variables between the two groups were compared with Independent-t test or Mann–Whitney U test according to the normal distribution of the variables. Chi-square test was performed for qualitative variables. The relationship between the parameters was assessed by using Pearson’s correlation and analysis. Multiple linear regression analysis was used to assess independent associations between the variables. The variance inflation factor (VIF) for independent variables was b5 in collinearity statistics. No evidence was found that would effect the linear and unbiased estimations which were related with error terms. The calculated p value b 0.05 was considered statistically significant.
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In the analysis of subscales of TCI; the mean scores of Explarotory Excitability, Shyness with Strangers, Attachment, and Spiritual Acceptance were significantly lower in Behcet’s patients compared to healthy controls, whereas the mean score of Self-Acceptance was higher in patients (Table 3). 3.3. The results of the correlations Persistance and Cooperativeness were positively correlated with age. Self-directedness was negatively correlated with Beck Anxiety scores. Self-Transcendence was positively correlated with Beck Anxiety and QOL (Table 4). Purposefulness, Helpfulness, Compassion, and Transpersonal identification were positively correlated with age. Disorderliness was negatively correlated with age. All those parameters were not correlated in controls except for Helpfulness. Responsibility was negatively correlated with Beck Anxiety scores. Self-Forgetfulness was positively correlated with QOL. Responsibility was negatively correlated with QOL. Disorderliness was negatively correlated with the duration of the disease (Table 5). 3.4. Correlations of BAI and BDI scores with QOL, disease activity and the duration of the disease BAI was positively correlated with QOL (r:0.677; p:0.000) and disease activity (r:366; p:0.012). BDI was positively correlated with QOL (r:0.676; p:0.000), disease activity (r:0.302; p:0.041) and the duration of the disease (r:0.309; p:0.037). 3.5. Multiple linear regression analysis of temperament and character ınventory properties associated with QOL Multiple linear regression analysis indicated that Responsibility was the major predictive factor of QOL (Table 6). 4. Discussion
3. Results 3.1. Clinical characteristics of the study subjects A total of 46 patients with BD diagnosed for more than 6 months participated in the study. Age, gender and educational level matched 40 healthy controls were enrolled in the study. There was no significant difference between the two groups in terms of gender, age and educational level. Descriptive and clinical characteristics of both case and control gropus are shown in Table 1. The score of QOL was higher in Behcet’s group than controls (p b 0.001). 3.2. The results of the temperament and character ınventory The mean score of Reward Dependence was lower in Behcet’s patients than healthy controls (Table 2). Reward Dependence scores were still significantly different from the healthy controls after controlling depression (t:3.126; p:0.003).
The present study aimed to determine the personality traits of Behcet’s patients compared with healthy controls using the TCI and to investigate whether personality related to quality of life and disease activity with the disease duration, depressive and anxiety symptoms in Behcet’s disease.
Table 4 Correlation coefficients between Temperament and Character Inventory and age, BAI, QOL and the duration of the disease.
Persistence Cooperativeness Self-Directedness Self-Transcendence ⁎ p b 0.05. ⁎⁎ p b 0.01.
Age (r-value)
BAI (r-value)
QOL (r-value)
⁎0.303 ⁎0.297 – –
– – ⁎−0.322 ⁎0.294
– – – ⁎⁎0.383
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Table 5 Correlation coefficients between the subscales of Temperament and Character Inventory and age, BAI, QOL and the duration of the disease.
Disorderliness Purposefulness Helpfulness Compassion vs revenge Transpersonal Identification Responsibility Self-Forgetfulness
Age (r-value)
BAI (r-value)
QOL (r-value)
Duration of the disease (r-value)
−0.450⁎⁎ 0.306⁎ 0.300⁎ 0.331⁎
– – – –
– – – –
−0.374⁎ – – –
0.397⁎⁎
–
–
–
– –
−0.322⁎
−0.370⁎ 0.315⁎
– –
⁎ p b 0.05. ⁎⁎ p b 0.01.
4.1. Personality traits of Behcet’s patients It’s known that BD is a chronic immunoinflammatory disease with periods of exacerbation and remission and may be induced by stress–immune system interaction [22,23]. The effect of stress in the relapse and remission cycle of BD was demonstrated in early studies. Anxiety and depression were found as two important indicators of stress [22,24]. It has been shown that personality traits play an important role in stress management, depression and anxiety [11]. Thus, we mainly studied the personality traits of BD patients and compared our results with healthy controls and other reports of chronic immunologic and dermatological disorders. Although several studies about personality traits and their effects on different chronic disorders like multiple sclerosis (MS), sarcoidosis, epilepsy, chronic fatigue syndrome, asthma and diabetes mellitus patients were performed before, there have been no previous reports about the personality traits of Behcet’s patients assessed by TCI or other methods [25–30]. Only a study conducted by Koptagel-Ilal et al., suggested that patients with BD had pathological personality structures, including weak ego, regressive tendencies, disturbed body image, high anxiety, difficulties in social adaptation, and coping with emotions [31]. Our results demonstrated that BD patients had lower Exploratory Excitability scores as a subdimension of Novelty-Seeking compared with healthy controls and that in terms of Cloninger’s personality traits patients with BD show less excitable reactions to a pleasant stimuli and have diminished positive affect and exploratory behavior [11]. Svrakic et al., reported that lower scorers of Exploratory Excitability were reserved [32]. They are resistant or slow to engage in new ideas and activities. These people are rarely bored and thus tend to stick with familiar routines even if there are new and better ways to do the same thing [33,15]. Nevertheless, shyness with strangers’ sub dimension of Harm Avoidance was lower in BD patients that we can assume BD patients are not shy in an unfamiliar situation. Other sub dimensions of Harm Avoidance and Novelty
Seeking scores were not different from healthy controls incompatible with the results of other psychosomatic disorders or MS. Ustun et al., reported that MS patients had higher harm avoidance and impulsiveness, and were pessimistic, avoidant and easily fatigued [34]. Most of the studies about chronic disorders like chronic tension type headache, anxiety disorders, depression, myotonic dystrophy, chronic fatigue syndrome, psoriasis and fibromyalgia demonstrated higher Harm Avoidance scores [6,28,35–38]. Although some studies had controversial results, Harm Avoidance scores were also found higher in most of the somatization disorders [39,40]. BD is a chronic disease but, our findings were not similar for Harm Avoidance scores with those chronic disorders which might be due to different etiopathogenetic mechanisms in BD. Besides our study group did not include patients with debilitating neurological complications and most of our patients were not depressive which might affect the results. Another different dimension in temperament was Reward Dependence. We found lower scores of Reward Dependence in BD patients than healthy controls. Reward Dependence describes the maintenance of behavior in response to cues of social reward. Low scores of Reward Dependence show that BD patients may have difficulties in social attachment which may result in relationship problems and susceptibility to psychiatric disorders like depression or adjustment problems. Low scorers on the Attachment subscale manifest more or less pronounced detachment and disinterest in social relationships. They prefer privacy over intimacy and are thus often described as self-contained. These individuals typically do not share their intimate feelings with others. They impress others as alienated, detached who are usually indifferent to rejection and insults [15,33]. Svrakic et al. regarded the lower scorers of attachment as cold personalities [32]. Fruyt et al. concluded that low Reward Dependence was related to introversion [41]. Since, introversion is a complex factor with loadings from high Harm Avoidance and low Reward Dependence, our findings showed that BD patients were just low in Reward Dependence indicating cold and detached personality traits. In accordance with our findings, Kim et al. found lower scores in Reward Dependence for atopic dermatitis patients and suggested that it might be linked to
Table 6 Multiple linear regression analyses associated with QOL in Behcet’s patients. Independent variables
Responsibility Self-forgetfulness Transpersonal identification R 2(multiple coefficient of determination)
Standart regression coefficients (β) QOL −0.304⁎ 0.151 0.162 0.206⁎
VIF values (Responsibility:1.088; Self-forgetfulness:1.418; Transpersonal identification:1.317). ⁎ p b 0.05.
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depressive symptoms [42]. But in our study Reward Dependence scores were still lower after controlling depressive symptoms. Therefore attachment problems should be considered carefully in BD patients during psychotherapeutic approaches. It’s known that temperament traits were found associated with neurophysiological circuits and neurotransmitter systems. Reward Dependence was shown associated with noradrenergic activity in the central nervous system [43]. Our study revealed remarkable results for Reward Dependence. In literature there are a limited number of researches about noradrenergic system in BD. Aksoyek et al. reported that BD patients had increased sympathetic and decreased parasympathetic modulation and suggested BD patients might have an asymptomatic autonomic nervous system dysfunction [44]. Tellioglu and Robertson indicated an autonomic dysfunction accompanied by abnormal catecholamine levels in a BD patient and suggested a contribution of an immunological damage to the components of neural pathways in the pathogenesis of the autonomic involvement [45]. Also in a recent case report, a BD patient with Sympathetic storms which were characterized by hyperactivity of autonomic functions had high levels of catecholamine and IL-8 in cerebrospinal fluid. The patient was treated with corticosteroids and intravenous cyclophosphamide. The concentrations of NE and IL-8 were decreased to normal levels after the improvement of the symptoms [46]. Our result for Reward Dependence is also pointing out norepinephrine disturbance that further studies about noradrenergic neuronal pathways, might be helpful in order to clarify the etiology, immunological and genetic patterns in BD patients. In character dimensions, the Self-Acceptance scores were higher in patients. This result was incompatible with the result of Ustun et al. who found lower scores in MS patients. Although there are many factors effecting Self-Acceptance, this result may be due to the clinical differences of MS that may be more destructive than BD and due to the MS study group which involved patients with fatigue [34]. The last character sub-dimension different from healthy controls was Spiritual Acceptance. We found lower scores in BD patients than controls and lower scores represent materialistic personalities as Cloninger et al. indicated before. These individuals are generally unwilling to accept things that cannot be scientifically explained. The disadvantage of lower scores for Spiritual Acceptance is those individuals may have difficulties when confronted by inevitable death, suffering, or unjust punishments [11,15]. 4.2. The relations of temperament and character properties with quality of life, disease activity, disease duration, anxiety and depression in BD We found that Responsibility which is a sub dimension of Self-Directedness is decreasing with the decrease of quality of life while Self-Transcendence and Self-Forget-
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fulness are increasing in BD patients. In other words lower quality of life in Behcet’s patients may cause some characteristic differences as they are less responsible and more intuitive. Besides our study demonstrated that patients are more stoical, persistent, purposeful, compassionate and acquiescent with the increase of age and those results were different from the healthy controls. We suggest that those differences in characteristics might be due to the psychosocial effects of BD. Disease activity was associated with anxiety and depression scores. But the temperament and character properties were not related with disease activity. In recent studies anxiety and depression were found to be associated with disease activity and quality of life in BD. Uguz et al. reported that major depression had a negative impact on QOL of BD patients and that QOL is negatively correlated with the severity of depressive symptoms [47]. Another study revealed positive correlations between BDI scores and patient's impression of disease activity in BD patients [5]. Our findings were concurrent with literature that depression and anxiety scores were positively correlated with the disease activity, duration of the disease and the QOL scores. In regression analysis, Responsibility, Self-Forgetfulness and Transpersonal Identification were negatively associated and Self-Transcendence was positively associated with quality of life and Responsibility was the major predictive factor for quality of life in Behcet’s patients. Celikel et al. reported lower Responsibility scores in major depressive disorder patients [48]. Our results were similar with those that showed that lower quality of life was correlated with depression and was related with responsibility subdimension in BD patients as well. Yoda et al. also showed a positive correlation between HbA1C and Responsibility scores for Type 2 diabetic patients [30]. There are several limitations to this study. The personality assessment was based on self-reporting questionnaire and was not objective. Also some of the patients did not accept to be involved our study due to the duration of the scale application which limited our sample size. Nevertheless, assessing the Temperament and Character traits of BD patients for the first time is the major strength of our study. In conclusion, this study suggests that BD patients have distinctive temperament such as Reward Dependence dimension compared with healthy controls. Patients with BD seem to be materialistic, self-contained, self-confident, cold, detached and reserved although they are not shy. These temperament and character differences may be due to many effects like genetics, socio-cultural influences or even due to a common neurologic pathway for BD and personality traits. Decreased quality of life and increased disease activity of the patients were correlated with increased anxiety and depression. Responsibility, Self-Forgetfulness, Transpersonal Identification and Self-Transcendence were associated with quality of life. Responsibility subdimension was the major factor effecting quality of life of BD patients which might be linked to depressive symptoms. In the future, longitudinal
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