Psychiatry Research 226 (2015) 357–360
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
The Zuckerman–Kuhlman personality questionnaire in bipolar I and II disorders: A preliminary report Shaofang Xu a, Qianqian Gao a, Liji Ma b, Hongying Fan a, Hongjing Mao c, Jian Liu c, Wei Wang a,c,n a
Department of Clinical Psychology and Psychiatry/School of Public Health, Zhejiang University College of Medicine, Hangzhou, China Department of Psychology, Zhejiang Police Vocational Academy, Hangzhou, China c Department of Clinical Psychology, Affiliated Psychiatric Hospital, Zhejiang University College of Medicine, Hangzhou, China b
art ic l e i nf o
a b s t r a c t
Article history: Received 28 October 2014 Received in revised form 4 December 2014 Accepted 19 January 2015 Available online 28 January 2015
Patients with bipolar disorder have tendencies of higher impulsivity and sensation seeking, they might contribute differently to the emotional states of bipolar I (BD I) and II (BD II). We administered the Zuckerman–Kuhlman Personality Questionnaire (ZKPQ), the Plutchik–van Praag Depression Inventory (PVP), the Mood Disorder Questionnaire (MDQ), and the Hypomania Checklist (HCL-32) in 23 patients with BD I, 22 BD II, and 64 healthy volunteers. Both BD I and II scored higher on ZKPQ Impulsive sensation seeking (and its Impulsivity facet), Neuroticism–anxiety and Aggression–hostility, and on PVP and HCL-32 scales than controls did; BD I scored higher on MDQ and General sensation seeking facet than controls did. Compared to BD II, BD I scored higher on Impulsive sensation seeking (and General sensation seeking) and on MDQ. Moreover, General sensation seeking predicted MDQ, and Activity predicted HCL-32 in BD I. Aggression–hostility predicted HCL-32 in BD II. General sensation seeking predicted MDQ and HCL-32, and together with Neuroticism–anxiety, predicted PVP in controls. Our study suggests that Impulsive sensation seeking, and its General sensation seeking facet might help to delineate the two types of bipolar disorder. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Emotional state Impulsive sensation seeking Mood disorder
1. Introduction The bipolar disorder often presents with succeeding episodes of mania, depression, and euthymia (i.e., no symptoms), which involves important fluctuations in mood, cognitive functioning, and social behavior. The clinical symptoms vary between its two major types, i.e., the bipolar I (BD I) and II (BD II), and between individuals (American Psychiatric Association, 2013). Considering that personality traits reflect the individual differences, scholars have studied the trait scores in bipolar disorder. For instance, using the NEO-PI-R (Costa and McCare, 1985), one big five-factor model of normal personality measure, Kim et al. (2012) found significantly higher Neuroticism and lower Extraversion traits in BD II than in BD I. Using NEO-PI-R and other temperament measures, Strong et al. (2007) failed to demonstrate a difference on the Neuroticism-alike trait in BD I and II. On the other hand, personality traits are associated with the affective states of bipolar disorder, but mainly are confined to those of BD I. For instance,
n Corresponding author at: Department of Clinical Psychology and Psychiatry/ School of Public Health, Zhejiang University College of Medicine, Yuhangtang Road 866, Hangzhou, Zhejiang 310058, China. Tel.: þ 86 571 88208188. E-mail addresses: [email protected], [email protected] (W. Wang).
http://dx.doi.org/10.1016/j.psychres.2015.01.019 0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
Neuroticism is positively correlated with depression, and Conscientiousness positively with mania in BD I (Lozano and Johnson, 2001). Normal personality traits can also be measured using the alternative five-factor model, the Zuckerman–Kuhlman Personality Questionnaire (ZKPQ, Zuckerman et al., 1993), which describes five domains namely Impulsive sensation seeking, Neuroticism– anxiety, Aggression–hostility, Activity and Sociability. The impulsivity trait-facet, which is characterized by a lack of forethought and a failure to contemplate risks and consequences before acting, has been treated as a stable feature of bipolar disorder (Swann et al., 2004; Saddichha and Schuetz, 2014). The manic state, which is often found in BD I, is highly connected with sensation-seeking (Zuckerman, 1994). In addition, the manic state of bipolar disorder and sensation seeking was biologically linked to monoamine oxidase activity (Zuckerman, 1985). Unfortunately, most facet levels of NEO-PI-R, such as the Impulsivity of Neuroticism and the Excitement-Seeking of Extraversion were not fully-studied in BD I and II previously (Strong et al., 2007; Kim et al., 2012). Therefore one might easily ask whether the Impulsive sensation seeking trait, which is composed of both Impulsivity and General sensation seeking facets, together with other four traits, could help to differentiate BD I and II disorders. In the current study, we have hypothesized that there were significant differences between BD I and II: (1) of ZKPQ personality
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traits, especially of Impulsive sensation seeking trait and its facet General sensation seeking; (2) of the emotional states, i.e., the mania, hypomania and depression; and (3) of the relationships between personality traits and the emotional states. Therefore, besides ZKPQ, we have administered the Mood Disorder Questionnaire (Hirschfeld et al., 2000), the Hypomania Checklist-32 (Angst et al., 2005), and the Plutchik–van Praag Depression Inventory (Plutchik and van Praag, 1987) in patients with BD I and II disorders as well as in the healthy volunteers (controls).
sensation seeking; (b) Neuroticism–anxiety (19 items); (c) Aggression–hostility (17 items); (d) Activity (17 items); and (e) Sociability (17 items). One point is given for each chosen item corresponding to personality traits. B. The PVP contains 34 items; each item has a three-point scale (0, 1 and 2), which corresponds to increasing depressive tendencies. C. The MDQ screens for a lifetime history of a manic or hypomanic syndrome, especially of manic symptoms, with 13 yes/no items derived from both DSM-IV criteria and clinical experience. D. The HCL-32 comprises 32 items for detecting hypomanic symptoms. Individuals were instructed to answer the forced-choice (yes or no) questions about emotions, thoughts, or behaviors, and to answer questions regarding the duration, the impact of family, social and work life, or people's reactions.
2. Methods
2.3. Statistics
2.1. Participants
Two-way ANOVA (i.e., group (3) scale (5)) was applied to the mean scores of ZKPQ scales, and one-way ANOVA was applied to the mean scores of MDQ, HCL-32, and PVP scales in the three groups. The post-hoc analysis by the Least Significant Difference test was employed to evaluate between-group differences and to estimate the 95% confidence interval (CI) for difference. The multiple linear regression with stepwise elimination was applied to investigate the impact of ZKPQ traits on the PVP, MDQ, and HCL-32 scale scores. A p value less than 0.05 was considered as significant.
Sixty-four healthy volunteers, who had no history of psychiatric or neurological abnormalities, were recruited from hospital, college staff-members and community; 23 patients with BD I, and 22 BD II, who were diagnosed according to the DSM-5 criteria (American Psychiatric Association, 2013) were invited to participate in the current study (Table 1). All participants had no history of alcohol or drug abuse. There were no significant differences regarding age (one-way ANOVA, F [2, 106]¼ 2.11, p¼0.13, MSE¼74.99), received education (F [2, 106]¼ 0.10, p¼ 0.91, MSE¼1.32), or gender (Pearson χ2 ¼ 2.30, p¼ 0.32) between groups. The study protocol was approved by a local Ethics Committee and all participants had given their written informed consents (the informed consents of the young adolescents were signed by their guardians). 2.2. Questionnaires Participants were asked to complete the following four questionnaires in Chinese in a quiet room. Brief descriptions of the questionnaires are given here. A. The ZKPQ provides five scales: (a) Impulsive sensation seeking (19 items), composed of two units, i.e. eight items of Impulsivity and 11 items of General
3. Results The internal reliabilities of the ZKPQ traits, PVP, MDQ and HCL32 scales of the current study were satisfactory (Table 2). ZKPQ scale scores were significantly different among the three groups (F [2, 106] ¼36.90, p o0.001, MSE ¼ 509.11). BD I group scored significantly higher than the healthy control group did on Impulsive sensation seeking (p o0.001, 95% CI: 2.60–6.07) (and specifically
Table 1 Demographic and clinical characteristics in the bipolar type I (BD I, n¼ 23) and II (BD II, n¼ 22) disorders, and the healthy volunteers (Controls, n ¼64).
Age (in years; mean 7 S.D., range) Gender (female:male) Year of education received (mean 7 S.D.) Obsessive–compulsive disorder (patient number) Sleep problem (difficulty falling into/unrefreshing sleep; patient number) Suicidal ideation (without attempt; patient number) Mania attack (number range) Hypomania attack (number range) Depression attack (number range) Medication (treatment)–naïve (patient number) Medicated with anxiolytics (alprazolam, clonazepam, or lorazepam; patient number) Medicated with antidepressants (fluoxetine or sertraline; patient number) Medicated with mood stabilizers (valproate or lithium; patient number)
BD I
BD II
Controls
21.047 5.66, 16–44 15:8 17.617 3.22 12 16 10 1–4 0–2 3–7 18 2 2 3
24.467 6.59, 13–41 17:5 17.277 4.08 14 15 11 – 1–6 4–10 17 4 3 1
23.56 7 5.85, 15–41 38:26 17.6773.69 – – – – – – – – – –
Table 2 Scale internal reliabilities (Alphas, in all participants), and mean scores ( 7 S.D.) of personality traits and the emotional states of patients with bipolar I (BD I, n¼23) and II (BD II, n¼ 22) disorders and of the healthy volunteers (Controls, n¼ 64). Alpha
Zuckerman–Kuhlman Personality Questionnaire Impulsive sensation seeking Impulsivity General sensation seeking Neuroticism–anxiety Aggression–hostility Activity Sociability Plutchik–van Praag Depression Inventory Mood Disorder Questionnaire Hypomania Checklist-32 Note: a b
p o 0.05 vs. Controls. p o0.05 vs. BD II.
0.77 0.69 0.72 0.86 0.73 0.63 0.68 0.94 0.78 0.86
Score BD I
BD II
Controls
11.52 7 2.98a,b 4.39 7 1.75a 7.137 1.96a,b 14.007 2.84a 8.487 3.67a 6.22 7 2.95 7.487 4.32 32.83 7 8.21a 9.26 7 1.54a,b 23.357 2.90a
9.05 7 4.47a 3.647 2.26a 5.417 2.82 13.007 2.93a 7.55 7 3.35a 7.50 7 3.53 6.917 2.91 33.327 7.59a 3.777 1.82 23.147 1.70a
7.19 73.45 2.44 71.98 4.75 72.49 6.02 72.90 5.17 72.75 6.02 72.83 7.83 72.77 9.3376.16 3.22 72.24 14.88 74.25
S. Xu et al. / Psychiatry Research 226 (2015) 357–360
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Table 3 Stepwise multiple regression results of predicting the Mood Disorder Questionnaire, the Hypomania Checklist-32, and the Plutchik–van Praag Depression Inventory by the Zuckerman–Kuhlman Personality Questionnaire traits in the healthy volunteers (Controls, n¼ 64) and patients with bipolar I (BD I, n¼ 23) and II (BD II, n ¼22) disorders. Controls aR2
BD I
BD II
aR2
Beta, predictor
The Mood Disorder Questionnaire 0.07 0.29 General sensation seekingb
0.18
0.47 General sensation seekingb
The Hypomania Checklist-32 0.11 0.36 Impulsive sensation seekinga 0.17 0.43 General sensation seekingb
0.29 0.29
0.57 Activitya 0.57 Activityb
Beta, predictor
aR2
Beta, predictor
0.18 0.18
0.47 Aggression–hostilitya 0.47 Aggression–hostilityb
The Plutchik–van Praag Depression Inventory 0.20 0.46 Neuroticism–anxietya 0.24 0.46 Neuroticism–anxietyb, 0.22 General sensation seekingb Note: aR2, adjusted R2. a b
Independent variables were Impulsive sensation seeking, Neuroticism–anxiety, Aggression–hostility, Activity and Sociability. Independent variables were Impulsivity, General sensation seeking, Impulsive sensation seeking, Neuroticism–anxiety, Aggression–hostility, Activity and Sociability.
on Impulsivity (p o0.001, 95% CI: 0.99–2.92) and General sensation seeking (p o0.001, 95% CI: 1.19–3.57) facets), Neuroticism– anxiety (p o0.001, 95% CI: 6.59–9.38), Aggression–hostility (p o0.001, 95% CI: 1.82–4.79) scales. BD II scored significantly higher than controls did on Impulsive sensation seeking (p¼ 0.04, 95% CI: 0.10–3.62) (and Impulsivity (p ¼0.02, 95% CI: 0.22–2.18)), Neuroticism–anxiety (p o0.001, 95% CI: 5.57–8.40), Aggression– hostility (p o0.01, 95% CI: 0.86–3.89) scales. BD I scored significantly higher than BD II did on Impulsive sensation seeking (p ¼0.02, 95% CI: 0.35–4.60) (and General sensation seeking (p ¼0.02, 95% CI: 0.26–3.18)) scale (Table 2). Significant differences were also found among three groups regarding PVP (F [2, 106]¼ 155.30, po0.001, MSE¼7446.01), MDQ (F [2, 106]¼ 76.84, po0.001, MSE¼318.40), and HCL-32 (F [2, 106]¼ 70.96, po0.001, MSE¼925.65) scale scores. BD I (PVP: po0.001, 95% CI: 20.16–26.84; HCL-32: po0.001, 95% CI: 6.73–10.21) and BD II (PVP: po0.001, 95% CI: 20.60–27.38; HCL-32: po0.001, 95% CI: 6.49–10.03) scored significantly higher than controls did on PVP and HCL-32 scales respectively; BD I scored significantly higher than BD II (po0.001, 95% CI: 4.29–6.69) and controls (po0.001, 95% CI: 5.06–7.02;) did on MDQ scale (also see Table 2). Regression results showed that Activity (po0.01) predicted HCL32 in BD I; Aggression–hostility (p¼0.03) predicted HCL-32 in BD II; Neuroticism–anxiety (po0.001) predicted PVP, and Impulsive sensation seeking (po0.01) predicted HCL-32 in controls. When Impulsivity and General sensation seeking facet scores were also involved as predictors, the prediction of Impulsive sensation seeking in controls became non-significant, instead General sensation seeking facet significantly predicted MDQ (p¼0.02) in BD I; predicted MDQ (p¼ 0.02), and HCL-32 (po0.001) in controls; together with Neuroticism– anxiety (po0.001), it predicted PVP (po0.05) in controls (Table 3).
4. Discussion This is the first time that we trialed the ZKPQ in patients with bipolar disorder. We found both BD I and II groups scored significantly higher on ZKPQ Impulsive sensation seeking trait, and on its Impulsivity facet than controls did, which was consistent with previous results relating to bipolar disorder (Swann et al., 2004; Feliu-Soler et al., 2013; Mathias de Almeida et al., 2013; Choi et al., 2014) or to mania (Moeller et al., 2001). BD I also scored higher on General sensation seeking facet than controls did, which were also in line with previous reports (Zuckerman, 1994). In addition, BD I scored higher than BD II did on Impulsive sensation seeking trait and its General sensation seeking facet, which was consistent with a previous investigation (Serretti and Olgiati, 2005).
In accordance with previous documentation (Akiskal et al., 2006; Strong et al., 2007), we found both BD I and II scored higher on Neuroticism–anxiety than controls did. Agreeing with the higher aggression found in bipolar disorder (Perroud et al., 2011; Ballester et al., 2014), we also demonstrated higher Aggression– hostility in both BD I and II. Furthermore, both BD I and II scored significantly higher on depression than controls did, which accorded with previous research works (Kim et al., 2012). BD I scored significantly higher on MDQ than both BD II and controls did, which was in line with previous results (Yang et al., 2011). Both BD I and II also scored significantly higher on HCL-32 than controls did, which was consistent with other studies (Angst et al., 2005). Moreover, our study demonstrated the relationships between ZKPQ traits and the emotional states respectively in BD I and BD II. In BD I, Activity predicted HCL-32 which was consistent with the clinical description that the hypomanic symptoms are characterized by an increase in goal-directed activity (American Psychiatric Association, 2013). In BD I and in controls, General sensation seeking facet predicted MDQ, supporting a previous notion that the manic state is connected with the sensation-seeking trait (Zuckerman, 1994). In BD II, Aggression–hostility predicted HCL-32, which was consistent with the phenomena that bipolar disorder patients had less agreeableness trait and lower treatment-compliance in clinics (Látalová, 2012). In controls, Impulsive sensation seeking (and its General sensation seeking facet) predicted HCL-32, which was consistent with a previous report (Giovanelli et al., 2013). In this group, Neuroticism–anxiety also predicted PVP, which fits nicely into the established relationship between neuroticism and depression (Bagby et al., 2008; Klein et al., 2011). Apparently, as a preliminary report, our study suffers from several design limitations such as the small sample sizes, no description of possible personality disorder comorbidity, and the inclusion of adolescent participants with developing traits such as self-identity which might interfere the current findings (Ryan and Deci, 2003). However, the higher ZKPQ Impulsive sensation seeking trait and its General sensation seeking facet in BD I, and the prediction of MDQ by the General sensation seeking facet in BD I, might help to discriminate the two types of bipolar disorder. Nevertheless, a larger sample trial of the facet version of the Zuckerman–Kuhlman–Aluja Personality Questionnaire (Aluja et al., 2010) in bipolar disorder patients would be more promising.
Acknowledgements The study was supported by a grant from the National Natural Science Foundation of China (No. 91132715) to Dr. W. Wang. SX and QG contributed equally to the work described in the report.
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Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
The Zuckerman–Kuhlman personality questionnaire in bipolar I and II disorders: A preliminary report Shaofang Xu a, Qianqian Gao a, Liji Ma b, Hongying Fan a, Hongjing Mao c, Jian Liu c, Wei Wang a,c,n a
Department of Clinical Psychology and Psychiatry/School of Public Health, Zhejiang University College of Medicine, Hangzhou, China Department of Psychology, Zhejiang Police Vocational Academy, Hangzhou, China c Department of Clinical Psychology, Affiliated Psychiatric Hospital, Zhejiang University College of Medicine, Hangzhou, China b
art ic l e i nf o
a b s t r a c t
Article history: Received 28 October 2014 Received in revised form 4 December 2014 Accepted 19 January 2015 Available online 28 January 2015
Patients with bipolar disorder have tendencies of higher impulsivity and sensation seeking, they might contribute differently to the emotional states of bipolar I (BD I) and II (BD II). We administered the Zuckerman–Kuhlman Personality Questionnaire (ZKPQ), the Plutchik–van Praag Depression Inventory (PVP), the Mood Disorder Questionnaire (MDQ), and the Hypomania Checklist (HCL-32) in 23 patients with BD I, 22 BD II, and 64 healthy volunteers. Both BD I and II scored higher on ZKPQ Impulsive sensation seeking (and its Impulsivity facet), Neuroticism–anxiety and Aggression–hostility, and on PVP and HCL-32 scales than controls did; BD I scored higher on MDQ and General sensation seeking facet than controls did. Compared to BD II, BD I scored higher on Impulsive sensation seeking (and General sensation seeking) and on MDQ. Moreover, General sensation seeking predicted MDQ, and Activity predicted HCL-32 in BD I. Aggression–hostility predicted HCL-32 in BD II. General sensation seeking predicted MDQ and HCL-32, and together with Neuroticism–anxiety, predicted PVP in controls. Our study suggests that Impulsive sensation seeking, and its General sensation seeking facet might help to delineate the two types of bipolar disorder. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Emotional state Impulsive sensation seeking Mood disorder
1. Introduction The bipolar disorder often presents with succeeding episodes of mania, depression, and euthymia (i.e., no symptoms), which involves important fluctuations in mood, cognitive functioning, and social behavior. The clinical symptoms vary between its two major types, i.e., the bipolar I (BD I) and II (BD II), and between individuals (American Psychiatric Association, 2013). Considering that personality traits reflect the individual differences, scholars have studied the trait scores in bipolar disorder. For instance, using the NEO-PI-R (Costa and McCare, 1985), one big five-factor model of normal personality measure, Kim et al. (2012) found significantly higher Neuroticism and lower Extraversion traits in BD II than in BD I. Using NEO-PI-R and other temperament measures, Strong et al. (2007) failed to demonstrate a difference on the Neuroticism-alike trait in BD I and II. On the other hand, personality traits are associated with the affective states of bipolar disorder, but mainly are confined to those of BD I. For instance,
n Corresponding author at: Department of Clinical Psychology and Psychiatry/ School of Public Health, Zhejiang University College of Medicine, Yuhangtang Road 866, Hangzhou, Zhejiang 310058, China. Tel.: þ 86 571 88208188. E-mail addresses: [email protected], [email protected] (W. Wang).
http://dx.doi.org/10.1016/j.psychres.2015.01.019 0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
Neuroticism is positively correlated with depression, and Conscientiousness positively with mania in BD I (Lozano and Johnson, 2001). Normal personality traits can also be measured using the alternative five-factor model, the Zuckerman–Kuhlman Personality Questionnaire (ZKPQ, Zuckerman et al., 1993), which describes five domains namely Impulsive sensation seeking, Neuroticism– anxiety, Aggression–hostility, Activity and Sociability. The impulsivity trait-facet, which is characterized by a lack of forethought and a failure to contemplate risks and consequences before acting, has been treated as a stable feature of bipolar disorder (Swann et al., 2004; Saddichha and Schuetz, 2014). The manic state, which is often found in BD I, is highly connected with sensation-seeking (Zuckerman, 1994). In addition, the manic state of bipolar disorder and sensation seeking was biologically linked to monoamine oxidase activity (Zuckerman, 1985). Unfortunately, most facet levels of NEO-PI-R, such as the Impulsivity of Neuroticism and the Excitement-Seeking of Extraversion were not fully-studied in BD I and II previously (Strong et al., 2007; Kim et al., 2012). Therefore one might easily ask whether the Impulsive sensation seeking trait, which is composed of both Impulsivity and General sensation seeking facets, together with other four traits, could help to differentiate BD I and II disorders. In the current study, we have hypothesized that there were significant differences between BD I and II: (1) of ZKPQ personality
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S. Xu et al. / Psychiatry Research 226 (2015) 357–360
traits, especially of Impulsive sensation seeking trait and its facet General sensation seeking; (2) of the emotional states, i.e., the mania, hypomania and depression; and (3) of the relationships between personality traits and the emotional states. Therefore, besides ZKPQ, we have administered the Mood Disorder Questionnaire (Hirschfeld et al., 2000), the Hypomania Checklist-32 (Angst et al., 2005), and the Plutchik–van Praag Depression Inventory (Plutchik and van Praag, 1987) in patients with BD I and II disorders as well as in the healthy volunteers (controls).
sensation seeking; (b) Neuroticism–anxiety (19 items); (c) Aggression–hostility (17 items); (d) Activity (17 items); and (e) Sociability (17 items). One point is given for each chosen item corresponding to personality traits. B. The PVP contains 34 items; each item has a three-point scale (0, 1 and 2), which corresponds to increasing depressive tendencies. C. The MDQ screens for a lifetime history of a manic or hypomanic syndrome, especially of manic symptoms, with 13 yes/no items derived from both DSM-IV criteria and clinical experience. D. The HCL-32 comprises 32 items for detecting hypomanic symptoms. Individuals were instructed to answer the forced-choice (yes or no) questions about emotions, thoughts, or behaviors, and to answer questions regarding the duration, the impact of family, social and work life, or people's reactions.
2. Methods
2.3. Statistics
2.1. Participants
Two-way ANOVA (i.e., group (3) scale (5)) was applied to the mean scores of ZKPQ scales, and one-way ANOVA was applied to the mean scores of MDQ, HCL-32, and PVP scales in the three groups. The post-hoc analysis by the Least Significant Difference test was employed to evaluate between-group differences and to estimate the 95% confidence interval (CI) for difference. The multiple linear regression with stepwise elimination was applied to investigate the impact of ZKPQ traits on the PVP, MDQ, and HCL-32 scale scores. A p value less than 0.05 was considered as significant.
Sixty-four healthy volunteers, who had no history of psychiatric or neurological abnormalities, were recruited from hospital, college staff-members and community; 23 patients with BD I, and 22 BD II, who were diagnosed according to the DSM-5 criteria (American Psychiatric Association, 2013) were invited to participate in the current study (Table 1). All participants had no history of alcohol or drug abuse. There were no significant differences regarding age (one-way ANOVA, F [2, 106]¼ 2.11, p¼0.13, MSE¼74.99), received education (F [2, 106]¼ 0.10, p¼ 0.91, MSE¼1.32), or gender (Pearson χ2 ¼ 2.30, p¼ 0.32) between groups. The study protocol was approved by a local Ethics Committee and all participants had given their written informed consents (the informed consents of the young adolescents were signed by their guardians). 2.2. Questionnaires Participants were asked to complete the following four questionnaires in Chinese in a quiet room. Brief descriptions of the questionnaires are given here. A. The ZKPQ provides five scales: (a) Impulsive sensation seeking (19 items), composed of two units, i.e. eight items of Impulsivity and 11 items of General
3. Results The internal reliabilities of the ZKPQ traits, PVP, MDQ and HCL32 scales of the current study were satisfactory (Table 2). ZKPQ scale scores were significantly different among the three groups (F [2, 106] ¼36.90, p o0.001, MSE ¼ 509.11). BD I group scored significantly higher than the healthy control group did on Impulsive sensation seeking (p o0.001, 95% CI: 2.60–6.07) (and specifically
Table 1 Demographic and clinical characteristics in the bipolar type I (BD I, n¼ 23) and II (BD II, n¼ 22) disorders, and the healthy volunteers (Controls, n ¼64).
Age (in years; mean 7 S.D., range) Gender (female:male) Year of education received (mean 7 S.D.) Obsessive–compulsive disorder (patient number) Sleep problem (difficulty falling into/unrefreshing sleep; patient number) Suicidal ideation (without attempt; patient number) Mania attack (number range) Hypomania attack (number range) Depression attack (number range) Medication (treatment)–naïve (patient number) Medicated with anxiolytics (alprazolam, clonazepam, or lorazepam; patient number) Medicated with antidepressants (fluoxetine or sertraline; patient number) Medicated with mood stabilizers (valproate or lithium; patient number)
BD I
BD II
Controls
21.047 5.66, 16–44 15:8 17.617 3.22 12 16 10 1–4 0–2 3–7 18 2 2 3
24.467 6.59, 13–41 17:5 17.277 4.08 14 15 11 – 1–6 4–10 17 4 3 1
23.56 7 5.85, 15–41 38:26 17.6773.69 – – – – – – – – – –
Table 2 Scale internal reliabilities (Alphas, in all participants), and mean scores ( 7 S.D.) of personality traits and the emotional states of patients with bipolar I (BD I, n¼23) and II (BD II, n¼ 22) disorders and of the healthy volunteers (Controls, n¼ 64). Alpha
Zuckerman–Kuhlman Personality Questionnaire Impulsive sensation seeking Impulsivity General sensation seeking Neuroticism–anxiety Aggression–hostility Activity Sociability Plutchik–van Praag Depression Inventory Mood Disorder Questionnaire Hypomania Checklist-32 Note: a b
p o 0.05 vs. Controls. p o0.05 vs. BD II.
0.77 0.69 0.72 0.86 0.73 0.63 0.68 0.94 0.78 0.86
Score BD I
BD II
Controls
11.52 7 2.98a,b 4.39 7 1.75a 7.137 1.96a,b 14.007 2.84a 8.487 3.67a 6.22 7 2.95 7.487 4.32 32.83 7 8.21a 9.26 7 1.54a,b 23.357 2.90a
9.05 7 4.47a 3.647 2.26a 5.417 2.82 13.007 2.93a 7.55 7 3.35a 7.50 7 3.53 6.917 2.91 33.327 7.59a 3.777 1.82 23.147 1.70a
7.19 73.45 2.44 71.98 4.75 72.49 6.02 72.90 5.17 72.75 6.02 72.83 7.83 72.77 9.3376.16 3.22 72.24 14.88 74.25
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Table 3 Stepwise multiple regression results of predicting the Mood Disorder Questionnaire, the Hypomania Checklist-32, and the Plutchik–van Praag Depression Inventory by the Zuckerman–Kuhlman Personality Questionnaire traits in the healthy volunteers (Controls, n¼ 64) and patients with bipolar I (BD I, n¼ 23) and II (BD II, n ¼22) disorders. Controls aR2
BD I
BD II
aR2
Beta, predictor
The Mood Disorder Questionnaire 0.07 0.29 General sensation seekingb
0.18
0.47 General sensation seekingb
The Hypomania Checklist-32 0.11 0.36 Impulsive sensation seekinga 0.17 0.43 General sensation seekingb
0.29 0.29
0.57 Activitya 0.57 Activityb
Beta, predictor
aR2
Beta, predictor
0.18 0.18
0.47 Aggression–hostilitya 0.47 Aggression–hostilityb
The Plutchik–van Praag Depression Inventory 0.20 0.46 Neuroticism–anxietya 0.24 0.46 Neuroticism–anxietyb, 0.22 General sensation seekingb Note: aR2, adjusted R2. a b
Independent variables were Impulsive sensation seeking, Neuroticism–anxiety, Aggression–hostility, Activity and Sociability. Independent variables were Impulsivity, General sensation seeking, Impulsive sensation seeking, Neuroticism–anxiety, Aggression–hostility, Activity and Sociability.
on Impulsivity (p o0.001, 95% CI: 0.99–2.92) and General sensation seeking (p o0.001, 95% CI: 1.19–3.57) facets), Neuroticism– anxiety (p o0.001, 95% CI: 6.59–9.38), Aggression–hostility (p o0.001, 95% CI: 1.82–4.79) scales. BD II scored significantly higher than controls did on Impulsive sensation seeking (p¼ 0.04, 95% CI: 0.10–3.62) (and Impulsivity (p ¼0.02, 95% CI: 0.22–2.18)), Neuroticism–anxiety (p o0.001, 95% CI: 5.57–8.40), Aggression– hostility (p o0.01, 95% CI: 0.86–3.89) scales. BD I scored significantly higher than BD II did on Impulsive sensation seeking (p ¼0.02, 95% CI: 0.35–4.60) (and General sensation seeking (p ¼0.02, 95% CI: 0.26–3.18)) scale (Table 2). Significant differences were also found among three groups regarding PVP (F [2, 106]¼ 155.30, po0.001, MSE¼7446.01), MDQ (F [2, 106]¼ 76.84, po0.001, MSE¼318.40), and HCL-32 (F [2, 106]¼ 70.96, po0.001, MSE¼925.65) scale scores. BD I (PVP: po0.001, 95% CI: 20.16–26.84; HCL-32: po0.001, 95% CI: 6.73–10.21) and BD II (PVP: po0.001, 95% CI: 20.60–27.38; HCL-32: po0.001, 95% CI: 6.49–10.03) scored significantly higher than controls did on PVP and HCL-32 scales respectively; BD I scored significantly higher than BD II (po0.001, 95% CI: 4.29–6.69) and controls (po0.001, 95% CI: 5.06–7.02;) did on MDQ scale (also see Table 2). Regression results showed that Activity (po0.01) predicted HCL32 in BD I; Aggression–hostility (p¼0.03) predicted HCL-32 in BD II; Neuroticism–anxiety (po0.001) predicted PVP, and Impulsive sensation seeking (po0.01) predicted HCL-32 in controls. When Impulsivity and General sensation seeking facet scores were also involved as predictors, the prediction of Impulsive sensation seeking in controls became non-significant, instead General sensation seeking facet significantly predicted MDQ (p¼0.02) in BD I; predicted MDQ (p¼ 0.02), and HCL-32 (po0.001) in controls; together with Neuroticism– anxiety (po0.001), it predicted PVP (po0.05) in controls (Table 3).
4. Discussion This is the first time that we trialed the ZKPQ in patients with bipolar disorder. We found both BD I and II groups scored significantly higher on ZKPQ Impulsive sensation seeking trait, and on its Impulsivity facet than controls did, which was consistent with previous results relating to bipolar disorder (Swann et al., 2004; Feliu-Soler et al., 2013; Mathias de Almeida et al., 2013; Choi et al., 2014) or to mania (Moeller et al., 2001). BD I also scored higher on General sensation seeking facet than controls did, which were also in line with previous reports (Zuckerman, 1994). In addition, BD I scored higher than BD II did on Impulsive sensation seeking trait and its General sensation seeking facet, which was consistent with a previous investigation (Serretti and Olgiati, 2005).
In accordance with previous documentation (Akiskal et al., 2006; Strong et al., 2007), we found both BD I and II scored higher on Neuroticism–anxiety than controls did. Agreeing with the higher aggression found in bipolar disorder (Perroud et al., 2011; Ballester et al., 2014), we also demonstrated higher Aggression– hostility in both BD I and II. Furthermore, both BD I and II scored significantly higher on depression than controls did, which accorded with previous research works (Kim et al., 2012). BD I scored significantly higher on MDQ than both BD II and controls did, which was in line with previous results (Yang et al., 2011). Both BD I and II also scored significantly higher on HCL-32 than controls did, which was consistent with other studies (Angst et al., 2005). Moreover, our study demonstrated the relationships between ZKPQ traits and the emotional states respectively in BD I and BD II. In BD I, Activity predicted HCL-32 which was consistent with the clinical description that the hypomanic symptoms are characterized by an increase in goal-directed activity (American Psychiatric Association, 2013). In BD I and in controls, General sensation seeking facet predicted MDQ, supporting a previous notion that the manic state is connected with the sensation-seeking trait (Zuckerman, 1994). In BD II, Aggression–hostility predicted HCL-32, which was consistent with the phenomena that bipolar disorder patients had less agreeableness trait and lower treatment-compliance in clinics (Látalová, 2012). In controls, Impulsive sensation seeking (and its General sensation seeking facet) predicted HCL-32, which was consistent with a previous report (Giovanelli et al., 2013). In this group, Neuroticism–anxiety also predicted PVP, which fits nicely into the established relationship between neuroticism and depression (Bagby et al., 2008; Klein et al., 2011). Apparently, as a preliminary report, our study suffers from several design limitations such as the small sample sizes, no description of possible personality disorder comorbidity, and the inclusion of adolescent participants with developing traits such as self-identity which might interfere the current findings (Ryan and Deci, 2003). However, the higher ZKPQ Impulsive sensation seeking trait and its General sensation seeking facet in BD I, and the prediction of MDQ by the General sensation seeking facet in BD I, might help to discriminate the two types of bipolar disorder. Nevertheless, a larger sample trial of the facet version of the Zuckerman–Kuhlman–Aluja Personality Questionnaire (Aluja et al., 2010) in bipolar disorder patients would be more promising.
Acknowledgements The study was supported by a grant from the National Natural Science Foundation of China (No. 91132715) to Dr. W. Wang. SX and QG contributed equally to the work described in the report.
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