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* Assoc. Prof. Dr., Department of Psychology, Ege University, ‹zmir, Turkey
Corresponding author: Haluk Arkar, Assoc. Prof. Dr. Department of Psychology Ege University Faculty of Literature 35100 Bornova ‹zmir Turkey E-mail: email@example.com Tel: +902323884000-1337
ABSTRACT Purpose: Suicidal behavior can be regarded as the consequence of the co-occurence of a personality characteristic underlying vulnerability and of state-dependent psychiatric problems. Further research has shown that personality characteristics including impulsivity and a disturbed regulation of anxiety or aggression may represent risk factors for suicidal behavior. The purpose of this study was to report relationship between attempted suicide and Cloninger’s personality dimensions of temperament and character in psychiatric patients. Method: The sample of the study consisted of a sample of 365 female and 179 male adult psychiatric patients, 20.6% (n=112) of whom had recently attempted suicide. Findings: Novelty seeking was a highly significant predictor with high scores observed in patients with and low scores in patients without attempted suicide. Low self-directedness scores were also a substantial predictor of the presence of attempted suicide. Discussion: Temperament dimension novelty seeking appears pertinent to explore suicidality and measurement of character dimensions may be useful in the clinical evaluation of suicide risk. Keywords: attempted suicide, personality, TCI ÖZET Türk Psikiyatri Hastalar›nda ‹ntihar Giriﬂimi ile Cloninger’in Kiﬂilik Boyutlar›n›n Mizaç ve Karakter Aras›ndaki ‹liﬂkileri Amaç: ‹ntihar davran›ﬂ›n›n, yatk›nl›k sa¤layan kiﬂilik özelli¤i ile durumsal psikiyatrik sorunlar›n birlikte oluﬂmas›n›n bir sonucu oldu¤unu söylemek mümkün görünmektedir. Araﬂt›rmalar, itkisellik (impulsivity) ve kayg› veya sald›rganl›¤›n bozuk düzenlenmesini içeren kiﬂilik özelliklerinin intihar davran›ﬂ› için risk faktörü oldu¤unu göstermektedir. Bu çal›ﬂman›n amac›, psikiyatri hastalar›nda intihar giriﬂimi ile Cloninger’in mizaç ve karakter kiﬂilik boyutlar› aras›ndaki iliﬂkileri bildirmektir. Yöntem: Çal›ﬂman›n örneklemi, %20.6’s› daha önce intihar giriﬂiminde bulunmuﬂ olan yetiﬂkin 365 kad›n ve 179 erkek psikiyatri hastas›ndan oluﬂmuﬂtur. Bulgular: Yenilik arama mizaç boyutu en anlaml› yorday›c› olarak bulunmuﬂ, intihar giriﬂimi olan hastalar yüksek, olmayanlar düﬂük puanlar alm›ﬂlard›r. Düﬂük kendini yönetme karakter boyutu puanlar› da intihar giriﬂiminin olup olmad›¤›n›n orta düzeyde yorday›c›s› olarak tesbit edilmiﬂtir. Sonuç ve Tart›ﬂma: Yenilik arama mizaç boyutu intihar niyetinin araﬂt›r›lmas›nda alâkal›d›r ve karakter boyutlar›n›n ölçümü de intihar riskinin de¤erlendirilmesinde yararl› olabilir. Anahtar Kelimeler: intihar giriﬂimi, kiﬂilik, TCI
New/Yeni Symposium Journal • www.yenisymposium.net
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and to adapt his behavior in accord with personal goals and values. Mann and Arango (1992) regarded suicidal behavior as the consequence of the co-occurence of a personality characteristic underlying vulnerability and of state-dependent psychiatric problems. Self-directedness corresponds to self-determination and “willpower”. thus. These temperament dimensions were assumed to be evolutionarily and genetically homogeneous and independent of one another. Harm Avoidance is a heritable bias to respond to aversive stimuli. Van Heeringen and colleagues demonstrated that the occurence of attempted suicide might be related to Cloninger’s personality characteristics “reward dependence” (Van Heeringen et al 2000) and “harm avoidance”. knowledge about their role in the pathogenesis of suicidal behaviour may contribute to the prediction and treatment of suicidal behavior. Recently. Furthermore. and “cooperativeness” (Van Heeringen et al 2003). Since most patients with depression do not show suicidal behavior. and borderline personality disorder (Hawton and Van Heeringen 2000). and Reward Dependence with low basal noradrenergic activity. Cloninger et al 1993). A major contribution has been made by psychological autopsy studies of individuals who committed suicide. Grucza and his co-workers (2003) reported that high “novelty seeking” is associated with past suicide attempts. leading to learned behavioral inhibition. temperament and character (Cloninger 1987. schizophrenia. and to the ability of an individual to control. Evidence is accumulating that suicidal behaviour may be associated with certain personality characteristics (Apter and Ofek 2001). The three character dimensions are Self-directedness. but in what manner remains to be explained. controlled studies of committed suicide (Lesage et al 1994) and of attempted suicide (Beautrais et al 1996) have found an increased prevalance of comorbid personality disorders characterized by impulsiveness and aggressive acts such as borderline and antisocial personality disorders. A patient with major depression has a 30-fold risk for suicide compared with an individual without depression. including the self. Cloninger first concentrated on three biogenetic dimensions of personality and developed the Tridimensional Personality Questionnaire (TPQ) to measure Novelty Seeking. Comorbidity of personality disorders with other psychiatric disorders contri- New/Yeni Symposium Journal • www. Novelty Seeking is a heritable tendency to respond to novelty and cues for reward that leads to exploratory activity in pursuit of rewards as well as avoidance of monotony and punishment. which reflect individual differences in goals. moderately stable throughout life. Cooperativeness refers to the ability to identify empathically with other individuals and. It is indisputable that psychiatric disorders are linked to suicide. and Reward Dependence. invariant despite social-cultural influences. Harm Avoidance. alcohol dependence. Through subsequent studies. “self-directedness”. Persistence was separated from Reward Dependence as a fourth dimension of temperament. the model was extended by including three character dimensions in order to be more comprehensive and to improve the assessment of personality disorders (Cloninger et al 1993). it has been argued that other factors than those eliciting depressive mood must operate when a person becomes suicidal. In these studies more than 90% of the deceased could retrospectively be given a psychiatric diagnosis dominated by major depression. to self esteem. These character dimensions are supposed to be influenced by social learning and are hypothesized to be less developed in immature personality and in personality disorders.net 111 Nisan 2010 | Cilt 48 | Say› 2 . 1993) and a disturbed regulation of anxiety or aggression (Van Praag 1996) may represent risk factors for suicidal behavior.yenisymposium. to regulate. As temperament dimensions are hypothetically associated with specific psychobiological systems. Self-transcendence refers to the awareness that all beings. values.INTRODUCTION Suicide and suicide attempts are common in psychiatric disorders. Major advances have been made in the study of the area of suicide research during the past 15 years. Recently. and self-conscious emotions. Further research has shown those personality characteristics including impulsivity and the regulation of anger (Apter et al. establish purposeful relationships. Cooperativeness. and Selftranscendence. In order to describe the structure and development of personality. Variation in each of the three temperament dimensions was supposed to be associated with a specific central monoaminergic system activity (Cloninger 1986): Novelty Seeking with low basal dopaminergic activity. Reward Dependence is a heritable tendency to respond to rewards and to maintain behaviors previously associated with reward. are integral participants in the evolution of the universe as a whole. and to involve preconceptual bias in perceptual memory and habit formation. Cloninger and his co-workers developed a general psychobiological model that accounts for both normal and abnormal variation in the two major components of personality. and it implies a tendency towards continuing and persevering despite fatigue and lack of reward. Harm Avoidance with high serotonergic activity.
The study of the personality dimensions of patients with attempted suicide may provide a clear insight into pathogenesis of suicidal behaviour.6 79. Reward Dependence: RD1-Sentimentality. Self-striving.1 37. The majority of the sample had some level of formal education ranging from primary school to university (high school. The three dimensions of characters are: Self-directedness: SD1-Responsibility vs.1 9. Unhelpfulness. The scale scores were obtained by adding the subscale scores under each scale.=13. university. and increases the risk of suicide. Cooperativeness: CO1-Social acceptance vs. RD3-Attachment vs.5 6.8%. RD4-Dependence vs. They were mostly married (54%). Selfconscious experience. 23%).6 Total 187 51 33 39 31 16 32 11 3 6 48 22 8 25 32 544 butes to suicidality.2 6. secondary school.5 93.5 68.3 10.6.9 62. SD2-Purposefulness vs. SD3-Resourcefulness.5 32.d.1 10. HA3-Shyness with strangers vs. Self-differentiation.9 89. Regimentation. Reserve.1 33.Table 1: Frequency and percentage of attempted suicide in relation to Axis 1 disorder Attempted Suicide Axis 1 disorder Major depression Schizophrenia OCD Panic disorder Adjustment disorder Dysthymia Alcohol Phobic disorder Eating disorder Psychosexual Dysfunction GAD Conversion disorder Paranoid disorder Bipolar disorder Other Total no 129 37 31 35 30 15 23 10 2 6 43 20 5 17 29 432 % 69. Empirical data supporting its psychometric properties and clinical applications are reported by Arkar and his co-workers (2005) and Köse and his co-workers (2004) in Turkey.0 27. HA2-Fear of uncertainity. Independence. Harm Avoidance: HA1-Anticipatory worry and pessimism vs. true/false format. Uninhibited optimism. 47. TCI is a 240-item. SD5-Congruent second nature.9 66. CO3-Helpfulness vs. Social intolerance. primary school. Procedure TCI was administered individually to the subjects.7 100 89. Blaming. Instrument The instrument used in the study was a questionnaire with a section on background information and the Temperament and Character Inventory (TCI). self-report. ST2-Transpersonal identification vs. 11.9). Gregariousness. NS3-Extravagance vs. METHOD Subjects The sample of the study consisted of a sample of 365 female and 179 male adult psychiatric patients (39 inpatients and 505 outpatients) who were admitted at Dokuz Eylül University Hospital Psychiatry Clinics (with a mean age of 37.6%.6%. Social disinterest. s. Reflection. It was used to assess the four dimensions of tem- perament and the three dimensions of character. The purpose of the present study was to report relationship between attempted suicide and Cloninger’s personality dimensions of temperament and character in psychiatric patients.0 90.0 9.0 72. SD4-Self-acceptance vs. Persistence. New/Yeni Symposium Journal • www. DSM-IV criteria based diagnoses can be seen in Table 1. HA4-Fatigability and asthenia vs.3 3. CO5-Pure-hearted conscience vs. Stoic rigidity. Self-serving advantage.8 71.4 20.net 112 Nisan 2010 | Cilt 48 | Say› 2 . Lack of goal-direction. Revengefulness.6 90. ST3-Spiritual acceptance vs. although a considerable number were single (35%). Vigor.4 9. Rational materialism. paper-and-pencil test. Detachment. TCI measures four higher-order dimensions of temperament and their lower-order traits: Novelty seeking: NS1-Exploratory excitability vs. NS4Disorderliness vs. Data were collected within the first month of admission for treatment. CO2-Empathy vs. thus potentially leading to new approaches to the treatment and prevention of suicidal behaviour. Self-Transcendence: ST1-Self-forgetful vs. NS2-Impulsiveness vs. CO4-Compassion vs.8 93.4 yes 58 14 2 4 1 1 9 1 1 5 2 3 8 3 112 % 31. 17.9 90.3 18.yenisymposium.7 96.
02 NS HA RD PER SD CO ST Constant 0. Prior to statistical analyses.01) reliably predicted attempted suicide. Novelty Seeking (NS). odds ratios and 95% confidence intervals for odds ratios for each of the seven predictors.89 0.02 -1.93 0. and fit between their distributions and the assumptions of multivariate analysis.02 0.7 62.000 0. Cooperativeness (CO).06 0.04 0.0 80. Overall. The mean scores and the standard deviations of Table 3: Attempted suicide classification table Predicted Suicide Actual Suicide Total % No Yes No 422 97 Yes 10 15 Correct % 97.02 1.259 0. Self-directedness (SD).10 1.21 0.04 0. all of the variables were examined through various SPSS programs for accuracy of data entry.356 0.94 0.07 0. missing values.98 1.02 0.4% is very low compared with specificity.yenisymposium.97 1. the model correctly classified 80. Persistence (PER).86 1. A direct logistic regression analysis was performed to predict the presence or absence of attempted suicide as a function of the seven TCI scales. The positive predictive value. 13. This page also included the questions on demographic characteristics.Table 2: Logistic regression analysis of attempted suicide as a function of the TCI scales 95% Confidence Interval Lower Upper Variables B S. The classification table for the model is shown in Table 3. FINDINGS The frequency and percentage of attempted suicide in relation to Axis 1 disorder is given in Table 1.02 0.07 6.94 0. The first page of the questionnaire included a general introduction to the study. Novelty Seeking (z=15.E.393 0. Harm Avoidance (HA). is 81%.04 0.98 0.86. All the statistical analyses were carried out by using the appropriate subprograms of the SPSS. According to the Wald criterion.99 1.04 -0. the negative predictive value.96 1. and information for the subjects to the effect that participation was on a volunteer basis. A direct logistic regression analysis was performed on attempted suicide as a function of the TCI scales. Wald Test (z-ratio) 15. and on the other hand. Sensitivity. Reward Dependence (RD).02 0. The similar result was found in persons (27.06 -0. is 60%.15 1.09 0. and Self-transcendence (ST). computed for the presence of attempted suicide.452 1. Wald statistics.001) and Self-directedness (z=6. Using one-way ANOVA.94 0. However.05 1. p<0.04 1. about suicide attempts just before hospitalization.02 0. Table 2 shows regression coefficients. which is 97. about previous suicide attempts (defined as any voluntary. the name and address of the investigator.44.3 New/Yeni Symposium Journal • www. Normality and linearity was checked and found to be satisfactory.7%.net 113 Nisan 2010 | Cilt 48 | Say› 2 . Fifty-eight of 187 persons (31%) with major depression had made at least one earlier suicide attempt.57 p Odds Ratio 1.06 -0.009 0. the subjects were helped in filling out the inventory when it was necessary.90 0.02 0. by gathering data.04 0. computed for the absence of attempted suicide.5%) with schizophrenia.087 0.06 Questionnaire had the necessary instructions. p<0. the mean TCI scale and subscale scores of patients with and without attempted suicide were compared with one another.09 1.3% of the cases. Suicidal behavior was assessed retrospectively and clinically. on the one hand.44 2.27 0. harmful behavior with a suicidal intent).00 0.
66) 7.22) 5.001 <0.56 41.s. SD1. RD1.26) 5.01 n.03) 5.31(1. HA4.35 31.79(1. Disorderliness.97) 3. Worry and pessimism.63) 4.Table 4: Means and standard deviations (in parentheses) of the TCI scales and subscales in psychiatric patients with and without attempted suicide.001 <0.12(1.14(2.83) F(df=1.09(1.69) 23.06 P <0.30) 24.18) 7. n. <0. ST2.s. On Novelty Seeking and Harm Avoidance scales.82(2.49(2. SD4.11) 4. and ST3 did not give a significant result.45) 5.69(1.23) 6.03(1.19(2.04(1. <0.001 <0.36(3.s.07(1.80) 2.46) 4.17 29. NS2.22 13.01 n.39 19. Shyness.44 6. and Self-Directedness.001 <0. and Self-forgetfulness subscales. CO4.16) 3.001 n.27) 13. and Principled subscales. SD3. Purposefulness. HA1.005 =0.29) 6. NS4.65(1.94(1.03) 6.94(2. <0.s. CO1.55(1.001 n.31) 5.72(2.94) 2.s.77) 4. DISCUSSION Logistic regression was carried out to predict the presence or absence of attempted suicide based on the TCI scales’ scores.47(7.76(2.79 the TCI scales and subscales in psychiatric patients with and without attempted suicide were calculated (see Table 4).24(5. patients with attempted suicide reported significantly lower scores than did patients without attempted suicide.24) 5.22(1.79(1.05 n. CO5. Congruent second nature.53) 5.79) 18.80(2. Fatigability.: not significant.85(2. and Attachment.83 15.63 11. 5.92) 4. Novelty seeking was a highly significant predictor with high scores observed in patients with and low scores in patients without attempted suicide.85) 2.96) 6.10) 2.75(3.53(2.41(2.47 47.39(6.89(2. SD5.001 n.001 <0.001 <0.45) 4.s.59(1.39(2. and ST1 were significant. patients with attempted suicide reported significantly higher scores than did patients without attempted su- icide. Self-trancendence.53) 4.38) 4. Further.21(2.yenisymposium.80 13. and RD3. Low self-directedness scores were also a substantial predictor of the presence of attempted suicide.69(1.35(2.542) 23.s. CO2. <0. CO3.001 n.63) 6.42 13.42) 6.98(5.14) 2. RD4.35) 4. Extravagance.10) 13.82) 26.89(2.41(1.62 11.01(2.64) 21.00) 5. NS3.90) No (n=432) 17. <0.s.19 9.s. n. <0.69(2.70(1.68) 6. Responsibility.60) 8.16(2. SD2.87) 3.77(2. NS1.001 =0. Social acceptance.001 <0.90(1. n. n. Reward Dependence.37) 4.33 38.65(1.50) 4.44 10.51) 4.67(1.62(2.55) 4.45(6.62(5.35(7.s. HA2.64(1.04) 5.44 7.79(1.53(2.21) 4.13) 4.56(1.24(5.001 =0. Attempted suicide Yes (n=112) Novelty Seeking Exploratory excitability (NS1) Impulsiveness (NS2) Extravagance (NS3) Disorderliness (NS4) Harm Avoidance Worry and pessimism (HA1) Fear of uncertainty (HA2) Shyness (HA3) Fatigability (HA4) Reward Dependence Sentimentality (RD1) Attachment (RD3) Dependence (RD4) Persistence Self-directedness Responsibility (SD1) Purposefulness (SD2) Resourcefulness (SD3) Self-acceptance (SD4) Congruent second nature (SD5) Cooperativeness Social acceptance (CO1) Empathy (CO2) Helpfulness (CO3) Compassion (CO4) Principled (CO5) Self-transcendence Self-forgetfulness (ST1) Transpersonal identification (ST2) Spiritual acceptance (ST3) n.00) 21. On Self-Directedness and Cooperativeness scales.41) 7.01(1.86) 4. differences were observed in patients with and New/Yeni Symposium Journal • www. Compassion.88) 5.26 11. 20. and Impulsiveness.12) 27.02(6. <0.82(2.93) 5.48) 16.11(2.s.s. One-way ANOVA procedure showed that the comparisons of psychiatric patients with and without attempted suicide on Novelty Seeking.99(2.001 n. and Harm Avoidance.30) 5. Helpfulness. HA3.91) 7.97) 3.79) 3.73(2.net 114 Nisan 2010 | Cilt 48 | Say› 2 . and Cooperativeness.10(5.001 =0.s.
Whitehead C. Alk›n T. Cloninger CR. Mulder RT. Sorias O. Relationships between suicidality and impulsivity in various psychopathological contexts have been reported (Mann et al 1999). Van Laere K. 106: 189-193. diagnostic. 12: 25-75. Congruent second nature (SD5). Understanding Suicidal Behaviour: the Suicidal Process Approach to Research. geçerlik ve güvenirli¤i. Beautrais et al 1996) have shown that personality disorders are common in patients who have committed suicide and in patients who made suicide attempts. Haas GL. Ofek H (2001) Personality Constellations in suicidal behaviour. impulsivity is a component of “novelty seeking”. St Louis.without attempted suicide on the TCI scale and subscale scores. Helpfulness (CO3). Arch Gen Psychiatry. Draganic S. both low self-directedness and cooperativeness have previously been found to increase the risk of suicide (Cloninger et al 1999). Worry and pessimism (HA1). 156: 181-189. Sar› Ö. Ayd›n N. This study suggests a temperamental characteristic to be associated with suicidal behavior. Kalelio¤lu U. Cimilli C (2005) Mizaç ve Karakter Envanteri’nin Türkçe formunun faktör yap›s›. Waternaux C. Malone KM (1999) Toward a clinical model of suicidal behavior in psychiatric patients. Klinik Psikofarmakoloji Bülteni. Arch Gen Psychiatry. 11: 7-67. Spitznagel EL. Reeves RA. and Self-forgetfulness (ST1) subscales. 60: 181-189. Slegers G. Nightingale SK (1996) Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case control study. Van de Wiele L. Menard-Buteau C. impulsivity and depressed mood in relation to violent and suicidal behaviour.yenisymposium. MO: Center for Psychobiology of Personality. treatment issues. Akvardar Y. 50: 975-990. Psychiatr Devel. Wetzel RD (1994) The Temperament and Character Inventory (TCI): A Guide to its Development and Use. Deavoll BJ. Lesage AD. Washington University. Van Heeringen K. Svrakic DM. güvenirli¤i ve faktör yap›s›. Loyer M (1994) Suicide and mental disorders: a case control study of young men. Akdede BB. Svrakic DM. Fergusson DM. Przybeck TR. Cloninger CR. 151: 1063-1068. and personality disorders: etioloic. 14: 139-163. editor. Apter A. Türk Psikiyatri Dergisi. Svrakic DM. 74: 149-158. in generally in the expected direction. 16: 190-204. The disadvantages of high ‘novelty seeking’ are related to excessive anger. Am J Psychiatry. In this study. character. Previous studies (Lesage et al 1994. CONCLUSION In conclusion. Arango V (1992) Integration of neurobiology and psychopathology in a unified model of suicidal behavior. Przybeck TR. Cloninger CR (1986) A unified biosocial theory of personality and its role in the development of anxiety states. Cloninger CR (1987) A systematic method for clinical description and classification of personality variants. Tunca Z. Przybeck TR. UK: Wiley. 50: 991-999. Audenaert K. and Attachment (RD3). Bayon C. and Principled subscales (CO5). Boyer R. Ak I. ﬁafak C. stressor-precipitated depression: a psychobiological hypothesis. Van Heeringen K. Hill K. Beautrais AL. anxiety/aggression-driven. J Affective Disord. Przybeck TR. Przybeck TR (1993) A psychobiological model of temperament and character. Przybeck TR. DC: American Psychiatric Press. Cloninger CR. and Impulsiveness (NS2). Cloninger CR (2004) Mizaç ve Karakter Envanteri: geçerlik. European Psychiatry. as patients showing suicidal behavior tend to be comparatively high in novelty seeking. Audenaert K. Van Heeringen K (2000) The International Handbook of Suicide and Attempted Suicide. patients with attempted suicide reported significantly lower scores than did patients without attempted suicide. Vanier C. Verstraete A (2000) Cortisol in violent suicidal behaviour: association with personality and monoaminergic activity. Köse S. Dumont F. Cloninger CR. quick decision making upon incomplete information. On Self-Directedness and Cooperativeness scales. Personality and psychopathology. REFERENCES Apter A. Extravagance (NS3). J Affective Disord. 87: 1-5. Sayar K. Chichester. Mann JJ. Van Praag H (1993) Anxiety. Purposefulness (SD2). 35-65. Przybeck TR (1999) Measurements of psychopathology as variants of personality. Fatigability (HA4). 74: 123-130. Treatment and Prevention. Mertens J. Acta Psychiatr Scand. Svrakic DM. Morisette R. Svrakic DM. Arch Gen Psychiatry. Also.. Arkar H. Mann JJ. Van Heeringen K. Shyness (HA3). Joyce PR.net 115 Nisan 2010 | Cilt 48 | Say› 2 . Bayon C. Responsibility (SD1). hopelessness and personality characteristics in attempted suicide. Dierckx RA (2003) Prefrontal 5-HT2a receptor binding index. ﬁahin S. Plutchik R. Grunberg F. editor. Cloninger CR (2002) Temperament. Cloninger RC (2003) Personality and depressive symptoms: a multi-dimensional analysis. Chichester. Poorly developed character traits are shared by all categorical subtypes of personality disorder (Svrakic et al 1993 and 2002). and poor control of impulses (Cloninger et al 1994). Washington. New/Yeni Symposium Journal • www. J Clin Psychopharmacol. patients with attempted suicide reported significantly higher scores than did patients without attempted suicide. Compassion (CO4). temperament dimension novelty seeking appears pertinent to explore suicidality and measurement of character dimensions may be useful in the clinical evaluation of suicide risk. comorbidity of personality disorders with other psychiatric disorders contributes to suicidality. Acta Psychiatr Scand. Van Praag HM (1996) Serotonin-related. On Novelty Seeking and Harm Avoidance scales. Am J Psychiatry. patients with attempted suicide showed comparatively lower scores on the character dimensions self-directedness and cooperativeness. Disorderliness (NS4). UK: Wiley. Am J Psychiatry. 153: 1009-1014. Cloninger CR (1993) Differential diagnosis of personality disorders by the seven factor model of temperament and character. 3: 167-226. Hawton K. J Affective Disord. Grucza RA. Further. Social acceptance (CO1). Özerdem A. 44: 573-588.
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