European Psychiatry 28 (2013) 483–491

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Original article

Temperament, character and personality disorders

P. Jylhä a,b, M. Ketokivi e, O. Mantere a,c, T. Melartin a,c, K. Suominen a,d, M. Vuorilehto a,c,
M. Holma a, I. Holma a,c, E. Isometsä a,c,*,f
a
Department of Mental Health and Substance Abuse Services, National Institute of Health and Welfare, Helsinki, Finland
b
Department of Psychiatry, Jorvi Hospital, Helsinki University Central Hospital, Espoo, Finland
c
Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland
d
City of Helsinki, Health Centre, Psychiatry, Helsinki, Finland
e
Operations and Technology Department, IE Business School, Madrid, Spain
f
Department of Psychiatry, Institute of Clinical Medicine, University of Helsinki, Helsinki, Finland

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To study, whether temperament and character remain stable over time and whether they differ
Received 15 April 2013 between patients with and without personality disorder (PD) and between patients with specific PDs.
Received in revised form 4 June 2013 Methods: Patients with (n = 225) or without (n = 285) PD from Jorvi Bipolar Study, Vantaa Depression
Accepted 6 June 2013
Study (VDS) and Vantaa Primary Care Depression Study were interviewed at baseline and at 18 months,
Available online 27 August 2013
and in the VDS also at 5 years. A general population comparison group (n = 264) was surveyed by mail.
Results: Compared with non-PD patients, PD patients scored lower on self-directedness and
Keywords:
cooperativeness. Cluster B and C PDs associated with high Novelty Seeking and Harm Avoidance,
Personality disorder
Comorbidity
respectively. In logistic regression models, sensitivity and specificity of Temperament and Character
Temperament Inventory (TCI) dimensions for presence of any PD were 53% and 75%, and for specific PDs from 11% to
Character 41% and from 92% to 100%, respectively. The 18-month test-retest correlations of TCI-R dimensions
Personality ranged from 0.58 to 0.82.
Conclusions: Medium-term temporal stability of TCI in a clinical population appears good. Character
scores differ markedly between PD and non-PD patients, whereas temperament scores differ only
somewhat between the specific PDs. However, the TCI dimensions capture only a portion of the
differences between PD and non-PD patients.
ß 2013 Elsevier Masson SAS. All rights reserved.

1. Introduction been consistently identified as problems [7] and have been

Personality disorders (PDs) are common psychiatric disorders
associated with significant distress or disability. Nearly one in 10
individuals in the community [32] and 30–50% of psychiatric
patients [28] have at least one PD. In clinical studies [28], the
majority of individuals meet the criteria of more than one PD, and
comorbidity within axis II disorders is common also in community
surveys [37]. Although stability should be a central defining
feature of axis II disorders in DSM-IV, in follow-up studies [16]
fewer than half of PD patients remain at or above the full criteria
for 2 years, and a significant diagnostic change of PDs may be seen
over a 6-month period [33]. Thus, a high rate of comorbidity
between PDs as well as instability of PD diagnoses over time have
* Corresponding author. Department of Psychiatry, Institute of Clinical Medicine,
University of Helsinki, P.O. Box 22, 00014 Helsinki, Finland. Tel.: +358 9 47163728;
fax: +358 9 47163735.
E-mail addresses: erkki.isometsa@hus.fi, erkki.isometsa@helsinki.fi
(E. Isometsä).
subjects of debate in the research agenda for DSM-5 [13].
Although in clinical decision-making categorical diagnoses are
useful, one alternative way to conceptualize PDs is as extremes
of normal personality traits. Cloninger postulated a unified
biopsychosocial theory of personality [11] that included four
predominantly genetically determined temperaments and three
predominantly developmentally determined character dimen-
sions. The different temperament dimensions were defined in
terms of basic stimulus-response characteristics. Novelty seeking
(NS) was thought to be related to the behavioural activation
system, harm avoidance (HA) to the behavioural inhibition
system, reward dependence (RD) to the behavioural maintenance
system and persistence (P) to perseverance in behaviour despite
frustration and fatigue. Of the character dimensions, self-
directedness (SD) referred to an individual’s ability to control,
regulate and adapt their behaviour in accord with chosen goals
and values, cooperativeness (C) to their tendency towards social
tolerance, empathy, compassion and helpfulness, and self-
transcendence (ST) to their identification with nature and their

0924-9338/$ – see front matter ß 2013 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.eurpsy.2013.06.003
484 P. Jylhä et al. / European Psychiatry 28 (2013) 483–491
Table 1
Subtyping personality disorders according to temperamental profiles, according to Cloninger [9].
Personality disorder Harm avoidance Novelty seeking
Schizotypal ? ?
Antisocial # "
Borderline " "
Narcissistic ? "
Avoidant " ?
Obsessive-compulsive " #
?: no predictions given in Cloninger’s original model.
ability to accept ambiguity and uncertainty. In theory, character
traits determined the presence or absence of any PD, whereas
temperament traits distinguished between specific PDs. The
dimensions are measured using a self-rating questionnaire, the
latest version being the Temperament and Character Inventory-
Revised (TCI-R).
A precondition for validity of the theory is temporal stability of
the traits. Stability of the TCI dimensions has mostly been studied
among healthy subjects [5,19,27,31]. In these studies, the 1-month
to 1-year test-retest correlations of TCI dimensions have ranged
from 0.53 to 0.94. Among psychiatric patients [14,31], the 1-month
test-retest correlations have been in the same range, but it remains
unclear whether the dimensional models of general personality
functioning demonstrate adequate levels of longer-term temporal
stability within clinical populations.
Several studies have analysed the relationship between
character dimensions and the presence of a PD. The presence of
any PD [1,6,14,29,35,36], number of PD diagnoses [1,29] and total
number of PD symptoms [29,35,36] have been found to be
consistently associated with low SD. The findings with C have been
more controversial. Most studies have found low C to be associated
with the number of PD diagnoses [14], the total number of PD
symptoms [29,35,36] or the presence of any PD [14,35], but some
studies [1,23] have reported no associations between C and PDs. ST
has correlated positively with severe PD, i.e. borderline, narcissistic
and schizotypal PD [35].
Temperament has been found to distinguish different person-
ality clusters. Subjects with cluster A (schizotypal, schizoid,
paranoid), B (antisocial, histrionic, borderline, narcissistic) and C
(avoidant, obsessive-compulsive, dependent, passive-aggressive)
PDs can be differentiated by low RD, high NS and high HA,
respectively [6,29,35,36]. However, there are mixed findings for
temperament to predict individual PDs. For example, in some
studies low RD has not been associated with schizotypal PD [29],
and high NS has not been associated with borderline [1],
narcissistic [29,36] or antisocial [29] PDs.
These inconsistencies might be partly explained by metho-
dological limitations of studies exploring the relationship
between PDs and the dimensions of temperament and character.
The PD patients have mostly been from tertiary care [1,35,36],
the potential influence of residual affective symptoms on
personality evaluation has been statistically controlled in only
a few studies [35] and self-report questionnaires, not clinical
interviews, have been used to make the PD diagnoses [35].
Moreover, only a few of these studies have included a general
population control group [35,36]. The number of PD patients
exceeded 100 in only three studies [2,14,29], and of these only
two also included character dimensions [14,29]. Thus, their
generalizability is limited.
The aim of this study was to investigate:
 the temporal stability of the dimensions of temperament and
character in a clinical sample;
 the differences of TCI dimensions between patients with and
without PD and subjects of the general population;
Reward dependence Persistence
? ?
# ?
# ?
" ?
" ?
# ?
 the associations of TCI dimensions with six specific PDs
(avoidant, obsessive-compulsive, schizotypal, narcissistic, bor-
derline and antisocial).
We hypothesized that the 18-month stability of temperament
and character would be at least as high as that of PD symptoms.
Based on Cloningers’s original hypothesis [8,9,11,36], we predicted
that:
 low SD and C would be common indicators of vulnerability to all
PDs, and low ST to severe PDs (borderline, narcissistic and
schizotypal);
 patients in clusters A, B and C PDs could be differentiated by low
RD, high NS and high HA, respectively, and separate PDs by
specific temperament profiles as shown in Table 1.
To test these hypotheses, we compared:
 PD patients between two time-points (baseline and 18-month
follow-up);
 PD and non-PD patients with normal controls;
 patients with a specific PD with non-PD patients.
2. Methods
Our patients came from three separate but comparable cohorts
of mood disorder patients (Jorvi Bipolar Study, JoBS; Vantaa
Depression Study, VDS; and Vantaa Primary Care Depression
Study, PC-VDS) and a general population survey, all conducted in
two adjacent cities (Espoo and Vantaa, combined population
408,270 in 2003) situated within the capital region of Finland. All
of these studies are collaborative research projects of the Mood
Disorder Research Unit, Department of Mental Health and
Substance Use, National Institute of Health and Welfare, Helsinki,
Finland, with the last author as the principal investigator. The
research protocols were approved by the Ethics Committee of
Helsinki University Central Hospital.
The detailed methodologies have been described elsewhere for
JoBS [25,26], VDS [20,28], PC-VDS [39,40] and the general
population survey [21].
3. JoBS, VDS and PC-VDS cohorts
3.1. Screening and baseline evaluation
In brief, 3547 psychiatric or primary care patients were
screened, and 1207 were interviewed face-to-face, resulting in
the recruitment of 597 patients with confirmed current and
lifetime DSM-IV axis I and II diagnoses. The patients were first
screened for bipolar disorder (BD, JoBS), major depressive disorder
(MDD, VDS) or MDD or subsyndromal depressive disorder (PC-
VDS) in an acute mood episode. After a positive screen or suspicion
of an incident episode, the patient was fully informed about the
study protocol and written informed consent was obtained. In
the second phase, a diagnosis was made by using all available
 P. Jylhä et al. / European Psychiatry 28 (2013) 483–491
information from face-to-face interviews and psychiatric records;
if the diagnosis was uncertain, other informants were contacted. In
JoBS and PC-VDS, the Structured Clinical Interview for DSM-IV axis
I disorders, research version with psychotic screen (SCID-I/P) [12],
and in VDS the World Health Organization Schedules for Clinical
Assessment in Neuropsychiatry (SCAN), version 2.0 [38] were used.
To exclude substance-induced mood disorder, MDD or subsyn-
dromal depressive disorder, patients who were currently abusing
alcohol or other substances were interviewed after 2–3 weeks of
abstinence. The final baseline cohorts consisted of 191 DSM-IV BD I
and II patients (JoBS), 269 DSM-IV MDD patients (VDS) and 137
depressive disorder patients (PC-VDS; 91 MDD patients and 46
patients with subsyndromal depressive disorder). Interrater
agreement in diagnostic interviews was excellent [25,28,39].
The current comorbid psychiatric diagnoses were assigned
during an acute phase of BD, MDD or subsyndromal depressive
disorder. Full DSM-IV axis I diagnoses (SCID-I/P in JoBS and PC-
VDS; SCAN in VDS) and axis II diagnoses (SCID-II for DSM-IV in JoBS
and PC-VDS; SCID-II for DSM-III-R in VDS) were made. Information
was also gathered on demographic characteristics, current
symptomatology using the Hamilton Depression Scale, HAM-D
[17], the Beck Depression Scale, BDI [4], the Beck Anxiety Scale, BAI
[3], and the Young Mania Rating Scale, YMRS [41], and illness
history using a retrospective life-chart [25,28].
3.2. Follow-up
After baseline assessments, patients were interviewed at
6 months (JoBS and VDS), at 18 months (JoBS, VDS and PC-VDS)
and at 5 years (VDS), with interviews typically lasting 2–3 hours.
Repeated SCID-I/P (JoBS and PC-VDS), SCAN 2.0 (VDS) and SCID-II
(JoBS and VDS at 18 months and VDS at 5 years) interviews and all
observer- and self-reported symptom scales were included at all
follow-up assessments. All medical and psychiatric records were
available. All available data on course of illness were then
integrated into the form of a graphic life-chart based on DSM-IV
criteria [20,26,40]. During the follow-up, the patients received
treatment as usual including pharmaco- and psychotherapy.
Of the 191 BD subjects from JoBS with a current phase initially
included in the study, 161 participated also in the 18-month follow-
up interview. They were somewhat older (mean 39.0 years, SD 11.9
vs. 33.7 years, SD 12.1, P = 0.007) than non-participants; no other
differences were evident in sociodemographic, clinical or personality
characteristics. Of the 269 VDS individuals with current MDD
initially included in the study, 182 were followed for 5 years, of
whom 163 were diagnosed as having MDD, 16 with BD, one with
schizophrenia and two with schizoaffective disorder. Of the 137 PC-
VDS patients, 127 were followed for 18 months. The diagnosis of four
patients switched to BD. The sociodemographic characteristics of the
patients in the JoBS, PC-VDS and VDS cohorts and the respondents of
the general population survey study are shown in Table 2.
3.3. TCI assessment
Personality was assessed in JOBS and in PC-VDS at baseline and
at the 18-month follow-up and in VDS at the 5-year follow-up by
using the 240-item Temperament and Character Inventory-
Revised (TCI-R) [10]. When filling in the TCI-R, the subjects were
instructed to think of the way they would typically act or feel.
4. General population survey
A total of 900 participants from Espoo and Vantaa aged 20–70
years were randomly drawn from the Population Register Centre in
Finland in 2003 [21]. The general population of these two cities is
similar to the rest of the country, except that Espoo has slightly
485
higher levels of education and employment. Only participants aged
20–60 years (n = 816) were included here. A self-report booklet
containing questions on sociodemographic characteristics, BAI,
BDI, TCI-R and an inquiry about whether the participant had ever
had a physician-diagnosed mental disorder (yes/no) was mailed to
all subjects.
Altogether 308 participants responded and gave their informed
consent. Non-responders were younger than responders (mean age
41.4 years, SD 10.6 vs. 42.5 years, SD 11.5, P < 0.001) and more often
male (62.3% vs. 48.5%, P < 0.001), but no difference was present in
the area of residence within the city [21]. Participants who reported
having a physician-diagnosed mental disorder (44/308) were
excluded; thus, 264 participants were included in this study.
4.1. Study design
To minimize the effect of mood, each patient’s personality
dimensions were determined at an index interview conducted when
HAM-D and YMRS scores (JoBS) were at a minimum. In the case of
only a single evaluation of either TCI-R or PD (general population
survey, VDS, PC-VDS), this was used as the index interview.
4.2. Statistical methods
Several parametric and non-parametric statistical methods
were used. Univariate analyses included Student’s t-test (inde-
pendent samples and paired samples), Pearson’s Chi2 test, one-way
analysis of variance (ANOVA), Fisher’s exact test and Cohen’s d. The
Pearson correlation coefficient (r) was used to test linear
associations. As the stability coefficients might be attenuated
due to imperfect measurement of the traits, the attenuation-
corrected stability coefficients are also reported for dimensional
measures [30]. The stability of categorical PD diagnoses was
assessed by using the Kappa coefficient. Cronbach’s alpha was
applied to assess internal consistency. Alphas were good in patient
cohorts for TCI-R scales (0.82–0.92) and personality disorder
diagnoses (JoBS and VDS: 0.59–0.89).
Several multinomial logistic and logistic regression analyses
were performed, all including age, gender, education, work status
and marital status as independent variables or covariates. BDI, BAI
and TCI scores from index interview also served as covariates in
the multinomial logistic regression model; belonging to any PD or
non-PD patient group or the general population group served as
the dependent variable. HAM-D, BAI and TCI scores from the index
interview also served as covariates in the final logistic regression
model; belonging to a specific PD or non-PD patient group served
as the dependent variable. Predictive power of logistic regression
models (with one or more TCI dimensions as independent
variables) to predict the outcome category correctly was assessed
by using the statistical measures of sensitivity, specificity and
positive and negative predictive value. In analysing the TCI scales
and the subscales, seven and 29 comparisons were made,
respectively; therefore, the corresponding significance levels were
set to the more conservative levels of 0.007 and 0.002. SPSS
software, version 17.0, was used.
5. Results
5.1. Test-retest of TCI and PD
The temporal stability of PD diagnoses was low. Test-retest
correlations of TCI-R dimensions ranged from 0.58 to 0.82.
Once corrected for attenuation due to unreliability, both TCI
dimensions and PD symptoms were fairly stable over time with
no notable differences, with the exception of narcissistic and
schizotypal PDs (Table 3).
486 P. Jylhä et al. / European Psychiatry 28 (2013) 483–491

Table 2
Sociodemographic characteristics and mean scores and standard deviations of the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Hamilton Depression Rating
Scale (HAM-D) and Temperament and Character Inventory (TCI-R) in the general population (n = 264) and in mood disorder patients without (n = 285) or with (n = 225)
personality disorder (PD).

Characteristic (I) General (II) Patients without (III) Patients with PD,
population (n = 264) PD, (n = 285) (n = 225)

n % n % n % x2
Sex 21.429**
Female 136 51.5 188 66.0 159 70.7
Male 128 48.5 97 34.0 66 29.3

Marital statusa 15.130*

Single 45 17.0 59 21.1 49 21.9
Married or cohabiting 168 63.6 144 51.4 111 49.6
Divorced 44 16.7 70 25.0 61 27.2
Widowed 7 2.7 7 2.5 3 1.3

Educationb 41.556**
University 48 18.4 35 12.5 25 11.3
Polytechnic 101 38.7 80 28.7 48 21.6
Vocational school 64 24.5 65 23.3 54 24.3
No professional education 48 18.4 99 35.5 95 42.8

Work statusc 67.760**

Employed 230 87.8 175 62.1 139 62.3
Student 13 5.0 25 8.9 14 6.3
Unemployed 12 4.6 40 14.2 37 16.6
Disability pensioned, psychiatric reason 0 0 34 12.1 25 11.2
Disability pensioned, somatic reason 7 2.7 8 2.8 8 3.6

Comorbid disorders evaluated at baseline

Any anxiety disorder, current 111 38.9 137 60.9 24.231**
Any alcohol use disorder, current 16 5.6 13 5.8

Comorbid PD evaluated at index interviewk

Avoidant 85 37.8
Obsessive-compulsive 63 28.0
Dependent 16 7.1
Passive-aggressive 37 16.4
Antisocial 35 15.6
Histrionic 6 2.7
Borderline 114 50.7
Narcissistic 15 6.7
Paranoid 46 20.4
Schizoid 4 1.8
Schizotypal 10 4.4
NOS 15 6.7

Number of PD diagnoses
1 106 47.1
2 62 27.6
3 30 13.3
4 14 6.2
5 13 5.8

Mean SD Mean SD Mean SD t-test

Age, year 42.5 11.5 41.9 12.2 39.8 13.2

HAM-Dk 7.7 6.9 11.2 6.8 5.828** (II < III)

ANOVA
I vs. II vs. III#
d,k
BDI 4.9 5.8 10.3 9.8 17.4 12.1 105.361** (I < II < III)

BAIe,k 5.9 6.6 11.3 10.9 19.5 13.1 1013.056** (I < II < III)

TCI-R
Harm avoidancef,k 86.4 18.0 101.4 18.3 112.2 18.6 125.020** (I < II < III)
Novelty seekingg,k 101.9 15.4 103.8 17.1 103.8 18.4 1.034, ns
Reward dependencef,k 103.1 14.6 100.5 14.6 96.1 16.3 12.691** (I, II > III)
Persistenceh,k 116.3 16.1 108.1 19.0 103.8 20.9 28.339** (I > II > III)
Self-directednessi,k 148.8 17.0 139.8 19.1 126.3 20.2 84.834** (I > II > III)
Cooperativenessf,k 137.7 14.1 134.7 16.2 125.5 19.0 34.518** (I, II > III)
Self-transcendencej,k 67.0 14.2 65.3 15.7 68.0 16.7 3.398* (II < III)

ANOVA: analyses of variance.

#
Significant differences based on post-hoc (Tukey) group comparisons.
*
P < 0.05.
**
P < 0.001.
a
Missing data 5/285, 1/225.
b
Missing data 3/264, 6/285, 3/225.
c
Missing data 2/264, 3/285, 2/225.
d
Missing data 1/264, 2/285.
e
Missing data 11/285, 5/225.
f
Missing data 22/285, 14/225.
g
Missing data 24/285, 14/225.
h
Missing data 1/264, 22/285, 14/225.
i
Missing data 23/285, 15/225.
j
Missng data 1/264, 24/285, 14/225.
k
Interview, when the scores of Hamilton Rating Scale for Depression were at minimum (the Jorvi Bipolar Study) or at 5-year follow-up (the Vantaa Depression Study) or at
baseline (the Primary Care Vantaa Depression Study).
 P. Jylhä et al. / European Psychiatry 28 (2013) 483–491 487

Table 3
Test-retest correlations for the Temperament and Character Inventory-Revised (TCI-R) and personality disorder (PD) during the 18-month follow-up in the Jorvi Bipolar Study
(JoBS, n = 191), the Vantaa Depression Study (VDS, n = 269) and the Primary Care Vantaa Depression Study (PC-VDS, n = 137).

JoBS VDS PC-VDS

TCI dimensions Dimensional Dimensional

Harm avoidance 0.68 (0.77) – – – 0.81 (0.91)

Novelty seeking 0.82 (0.94) – – – 0.81 (0.98)
Reward dependence 0.78 (0.89) – – – 0.73 (0.88)
Persistence 0.59 (0.65) – – – 0.81 (0.88)
Self-directedness 0.58 (0.68) – – – 0.74 (0.86)
Cooperativeness 0.77 (0.85) – – – 0.81 (0.92)
Self-transcendence 0.64 (0.72) – – – 0.81 (0.93)

Personality disorder Categorical Dimensional Categorical Dimensional –

Avoidant 0.53 0.61 (0.75) 0.40 0.56 (0.64) –
Obsessive-compulsive 0.51 0.53 (0.89) 0.35 0.41 (0.54) –
Schizotypal – 0.20 (0.29) – 0.47 (0.71) –
Narcissistic – 0.39 (0.49) – 0.44 (0.56) –
Borderline 0.31 0.53 (0.66) 0.37 0.53 (0.64) –
Antisocial – 0.74 (0.98) – 0.63 (0.72) –

Pearson correlation coefficients for the TCI-R and the number of PD symptoms (dimensional) and Kappa coefficients for categorical PD diagnosis. As the stability coefficients
are attenuated due to imperfect measurement of the traits, the attenuation-corrected stability coefficients for dimensional measures are shown in parentheses. TCI-R was
assessed at baseline and at 18-month follow-up in JoBS and in PC-VDS. PD diagnosis was assessed at baseline (JoBS, VDS and PC-VDS) and at 18-month-follow-up (JoBS and
VDS). Empty cells indicate that data were unavailable to calculate these coefficients.

5.2. Comparisons of PD patients with non-PD patients and the general
population group
PD patients scored higher on HA (d = 1.4) and lower on RD
(d = 0.5), P (d = 0.7), SD (d = 1.2) and C (d = 0.7) than subjects from
the general population.
Compared with non-PD patients, PD patients scored higher on
HA (d = 0.8) and lower on RD (d = 0.3), P (d = 0.2), SD (d = 0.7), C
(d = 0.5) and ST (d = 0.2).
In a multinomial logistic regression model comparing PD and
non-PD patients (Table 4), being a PD patient was associated with
higher HA (OR = 1.027, P < 0.001) and lower SD (OR = 0.975,
P < 0.001) and C (OR = 0.966, P < 0.001).
The subscale level findings are presented in Table 4.
Estimated from the logistic regression models with TCI dimen-
sions as independent variables and being a PD or non-PD patient as a
dependent variable, the sensitivity and specificity for SD alone was
51.9% and 76.0%, respectively, and for C alone 44.1% and 79.8%,
respectively. Adding HA and the remaining TCI dimensions did not
appreciably improve the measures. From the final model with both
SD and C as independent variables, sensitivity, specificity and
positive and negative predictive values were 52.9%, 75.2%, 63.1% and
66.5%, respectively.
5.3. Comparisons of specific PD with non-PD patients
Patients with avoidant PD scored higher on HA (d = 1.5) and
lower on RD (d = 0.6), P (d = 0.6), SD (d = 1.0) and C (d = 0.6) than
patients without PD.
Patients with obsessive-compulsive PD scored higher on HA
(d = 0.6) and lower on NS (d = 0.4), RD (d = 0.4), SD (d = 0.5) and C
(d = 0.5) than patients without PD.
Compared with patients without PD, patients with schizotypal
PD scored higher on ST (d = 1.4).
Patients with narcissistic PD scored higher on NS (d = 0.6) and P
(d = 0.6) and lower on SD (d = 1.0) and C (d = 0.9) than patients
without PD.
Patients with borderline PD scored higher on HA (d = 0.4), NS
(d = 0.3) and ST (d = 0.4) and lower on SD (d = 1.0) and C (d = 0.7)
than patients without PD.
The number of borderline PD symptoms correlated negatively
with NS scores (r = 0.191, P < 0.001).
Patients with antisocial PD scored higher on HA (d = 0.9), NS
(d = 1.0) and ST (d = 0.5) and lower on RD (d = 0.3), P (d = 0.6), SD
(d = 1.3) and C (d = 0.9) than patients without PD.
The logistic regression models comparing specific PD with non-
PD patients are shown in Table 5.
6. Discussion
In mood disorder patients, we tested Cloninger’s theory of the
relationships between temperament, character and personality
disorder. In line with Cloninger’s theory, we found that the scores
of character differed between PD and non-PD patients and the
scores of temperament distinguished most of the specific PDs. Two
character dimensions, self-directedness and cooperativeness, were
lower in PD patients than non-PD patients or subjects of the
general population. Being a PD patient was also associated with
higher harm avoidance. A logistic regression model with SD and C
as independent variables correctly predicted the DSM-IV PD
diagnosis moderately, in 53% of cases. The temporal stability of TCI
dimensions was good and at the same level as the stability of PD
symptoms.
The findings must be weighed against the strengths and
limitations of the study. Unlike most previous studies, we were
able to compare the temperament and character in PD and non-PD
patients and controls, and controlled for the possible confounding
effects of depressive, anxiety and manic symptoms as these
symptoms might inflate the TCI scores. Other major strengths of
our study were the relatively large number and representativeness
of mood disorder patients with and without PD and the few drop-
outs. Altogether 84% of the bipolar disorder patients and 75% of the
depressive patients could be interviewed at two time-points. The
general population sample was randomly drawn and represented
the suburban and urban populations of two large Finnish cities.
Some limitations must also be disclosed. First, all of the patients
were members of mood disorder research cohorts. Although the
cohorts were highly representative of usual primary care or
secondary level psychiatric care patients, this fact nevertheless
influences the generalizability of our findings. The response rate
(37.7%) and sample size (n = 264) of the general population sample
were also moderate [21]. Although the overlap of the personality
scores between the general population sample and the patient
cohort corresponded to that of other studies [18], how much the
488 P. Jylhä et al. / European Psychiatry 28 (2013) 483–491

Table 4
Multinomial logistic regression models for mood disorder patients to have personality disorder (PD)a.

Patients with PD Patients without PD General population

b 2
Variable OR OR 95%CI Wald x P OR 95%CI Wald x2 P
c
Harm avoidance 1.0 0.973 0.961–0.986 17.049 < 0.001 0.945 0.931–0.960 52.204 < 0.001
HA1 (anticipatory worry) 1.0 0.932 0.898–0.967 14.194 < 0.001 0.845 0.807–0.885 51.102 < 0.001
HA2 (fear of uncertainty) 1.0 0.981 0.942–1.022 0.820 0.365 0.914 0.872–0.959 13.437 < 0.001
HA3 (shyness) 1.0 0.951 0.917–0.986 7.257 0.007 0.925 0.886–0.965 13.106 < 0.001
HA4 (fatigability and asthenia) 1.0 0.970 0.934–1.008 2.456 0.117 0.837 0.797–0.878 51.444 < 0.001

Novelty seeking 1.0 1.007 0.995–1.019 1.213 0.271 1.008 0.994–1.023 1.311 0.252
NS1 (exploratory excitability) 1.0 1.016 0.981–1.053 0.793 0.373 1.055 1.011–1.102 6.093 0.014
NS2 (impulsiveness) 1.0 0.994 0.961–1.028 0.128 0.720 0.969 0.930–1.009 2.322 0.128
NS3 (extravagance) 1.0 1.011 0.983–1.040 0.571 0.450 1.002 0.970–1.036 0.021 0.883
NS4 (disorderliness) 1.0 1.021 0.974–1.070 0.740 0.390 1.038 0.981–1.098 1.653 0.199

Reward dependencec 1.0 1.014 1.000–1.028 3.642 0.056 1.032 1.015–1.050 13.256 < 0.001
RD1 (sentimentality) 1.0 1.022 0.977–1.068 0.909 0.340 1.072 1.017–1.130 6.648 < 0.001
RD2 (openness) 1.0 1.033 1.001–1.065 4.187 0.041 1.062 1.024–1.102 10.209 0.001
RD3 (attachment) 1.0 1.033 0.992–1.076 2.436 0.119 1.062 1.012–1.115 5.943 0.015
RD4 (dependence) 1.0 1.022 0.965–1.082 0.531 0.466 1.035 0.968–1.106 1.028 0.311

Persistencec 1.0 1.009 0.999–1.020 2.869 0.090 1.035 1.022–1.048 27.146 < 0.001
P1 (eagerness) 1.0 1.028 0.994–1.064 2.533 0.112 1.094 1.049–1.141 17.557 < 0.001
P2 (work hardened) 1.0 1.043 1.003–1.084 4.564 0.033 1.151 1.096–1.208 32.239 < 0.001
P3 (ambitious) 1.0 1.004 0.973–1.036 0.070 0.791 1.102 1.060–1.145 24.252 < 0.001
P4 (perfectionist) 1.0 0.991 0.953–1.030 0.214 0.644 1.044 0.997–1.093 3.413 0.065

Self-directedness 1.0 1.025 1.012–1.038 14.80 < 0.001 1.035 1.020–1.051 21.454 < 0.001
SD1 (responsibility) 1.0 1.098 1.047–1.151 14.952 < 0.001 1.138 1.077–1.201 21.438 < 0.001
SD2 (purposefulness) 1.0 1.053 1.002–1.106 4.090 0.043 1.160 1.092–1.232 23.374 < 0.001
SD3 (resourcefulness) 1.0 1.071 1.011–1.135 5.501 0.019 1.196 1.114–1.284 24.283 < 0.001
SD4 (self-acceptance) 1.0 1.033 1.003–1.063 4.660 0.031 0.938 0.905–0.971 12.702 < 0.001
SD5 (congruent second nature) 1.0 1.041 1.005–1.079 4.936 0.026 1.111 1.064–1.161 22.201 < 0.001

Cooperativeness 1.0 1.024 1.011–1.037 12.804 < 0.001 1.032 1.016–1.049 15.944 < 0.001
C1 (social acceptance) 1.0 1.049 1.003–1.097 4.388 0.036 1.089 1.032–1.149 9.607 0.002
C2 (empathy) 1.0 1.087 1.014–1.165 5.586 0.018 1.163 1.071–1.264 12.841 < 0.001
C3 (helpfulness) 1.0 1.112 1.054–1.173 14.979 < 0.001 0.993 0.932–1.058 0.046 0.831
C4 (compassion) 1.0 1.059 1.022–1.099 9.681 0.002 1.046 1.001–1.093 4.077 0.043
C5 (pure-hearted) 1.0 1.069 1.021–1.119 7.973 0.005 1.081 1.023–1.142 7.564 0.006

Self-transcendence 1.0 0.995 0.982–1.008 0.516 0.473 1.022 1.006–1.038 7.484 0.006
ST1 (self-forgetful) 1.0 0.984 0.952–1.016 1.003 0.317 1.038 0.999–1.078 3.572 0.059
ST2 (transpersonal identification) 1.0 0.995 0.956–1.036 0.055 0.814 1.074 1.025–1.126 9.094 0.003
ST3 (spiritual acceptance) 1.0 1.002 0.973–1.031 0.015 0.904 1.021 0.987–1.055 1.425 0.233

Statistically significant after Bonferroni correction are at bold.

a
Variables entered separately into the model. Adjusted for possible confounding sociodemographic factors (age, gender, education, work status, marital status), and the
scores of Beck Depression Inventory and Beck Anxiety Inventory as the temperament and character scores might be influenced by these symptom scores.
b
Reference group.
c
At index interview, when scores on the Hamilton Depression Rating Scale were at a minimum (the Jorvi Bipolar Study), or at 5-year follow-up (the Vantaa Depression
Study) or at baseline (the Primary Care Vantaa Depression Study).

moderate response rate biased the personality profiles of the
general population sample in a healthier direction remains
unknown. Small differences were also present between responders
to the general population survey and the general population in
sociodemographic characteristics. Moreover, we focused only on
the six PDs included in the draft proposal of the DSM-5 and
deliberately excluded patients with soft bipolar spectrum dis-
orders from the bipolar cohort [25]. Finally, a post-morbid change
of personality of the patients cannot be excluded.
The question of how accurate a patient’s self-rated evaluation of
him-/herself is compared with a clinician-made PD diagnosis is
intriguing and also of clinical importance. We found that during
the 18-month follow-up the temporal stability of the TCI
dimensions was high and at the same level as that of PD
symptoms, with the possible exception of narcissistic and
schizotypal PDs. The temporal stability of PD diagnoses, by
contrast, was low. This is in line with earlier findings of relative
temporal instability of PD diagnoses and stability of PD symptoms
and personality traits [34]. Thus, patients’ TCI evaluations of
themselves seem to be at least as reliable and stable as personality
disorders symptom evaluations made by clinicians.
We tested among mood disorder patients Cloninger’s hypoth-
esis that character would differ between PD and non-PD patients.
Our study confirmed the hypothesis that low SD and C are most
consistently associated with having any PD. This is in line with
most earlier findings of SD and C [29,36], contradicting the few
reports where no connection between PD and low C was found
[1,23]. In accordance with some previous studies [23,36], high HA
was also observed to be associated with being a PD patient, even
after controlling for depression, anxiety, age, gender and other
confounding sociodemographic factors. Moreover, as hypothesized
with severe PDs, high ST was associated with schizotypal PD and
with the number of borderline PD symptoms. The logistic
regression model with TCI dimensions as independent variables
correctly predicted the PD diagnosis only moderately, in 53% of
cases. However, the essential features of PDs are impairments in
self- and interpersonal functioning, as proposed also in the draft
proposal of the DSM-5 website (www.apa.org).
Cloninger postulated that temperament will distinguish
different personality disorders. Our study partly confirmed this
hypothesis. Both avoidant and obsessive-compulsive PDs were
associated with high HA and low NS, in accordance with former
 P. Jylhä et al. / European Psychiatry 28 (2013) 483–491 489

Table 5
Logistic regression models for mood disorder patients to have a personality disorder (PD).

Patients without PD (n = 285) Avoidant PD (n = 85) Diagnostic testsp

a,c b 2
Variable OR OR 95%CI Wald x P Se (41%) Sp (93%) PPV (64%) NPV (84%)

d
Harm avoidance 1.0 1.099 1.071–1.128 50.881 < 0.001
HA1 (anticipatory worry) 1.0 1.233 1.158–1.316 41.447 < 0.001
HA2 (fear of uncertainty) 1.0 1.168 1.089–1.253 18.864 < 0.001
HA3 (shyness) 1.0 1.238 1.154–1.329 35.314 < 0.001
HA4 (fatigability and asthenia) 1.0 1.120 1.059–1.183 16.087 < 0.001

Novelty seekinge 1.0 0.974 0.957–0.991 8.861 0.003

NS1 (exploratory excitability) 1.0 0.897 0.852–0.946 16.344 < 0.001

Reward dependencef 1.0 0.963 0.944–0.983 13.183 < 0.001

RD2 (openness) 1.0 0.883 0.841–0.927 25.132 < 0.001
RD3 (attachment) 1.0 0.891 0.841–0.944 15.319 < 0.001

Persistencef 1.0 0.972 0.957–0.987 13.103 < 0.001

P2 (work hardened) 1.0 0.872 0.822–0.924 21.260 < 0.001

Self-directednesse 1.0 0.953 0.936–0.971 25.072 < 0.001

SD1 (responsibility) 1.0 0.859 0.802–0.921 18.465 < 0.001
SD2 (purposefulness) 1.0 0.842 0.781–0.907 20.416 < 0.001
SD3 (resourcefulness) 1.0 0.783 0.719–0.854 30.952 < 0.001

Cooperativenessf 1.0 0.968 0.951–0.985 13.548 < 0.001

C1 (social acceptance) 1.0 0.883 0.823–0.948 11.989 0.001
C2 (empathy) 1.0 0.821 0.742–0.909 14.590 < 0.001
C3 (helpfulness) 1.0 0.870 0.809–0.935 14.245 < 0.001
Self-transcendence 1.0 0.994 0.976–1.013 0.340 0.560

Patients without PD (n = 285) Obsessive-compulsive PD (n = 63) Diagnostic testsp

b 2
Variable OR OR 95%CI Wald x P Se (18%) Sp (98%) PPV (73%) NPV (84%)

Harm avoidanceg 1.0 1.033 1.014–1.053 11.678 0.001

Novelty seekingg 1.0 0.973 0.955–0.991 8.481 0.004
Reward dependenceh 1.0 0.973 0.952–0.994 6.46 0.011
Persistenceh 1.0 1.011 0.995–1.027 1.679 0.195
P4 (perfectionist) 1.0 1.123 1.053–1.197 12.579 < 0.001
Self-directednessg 1.0 0.981 0.964–0.995 4.884 0.027
Cooperativenessh 1.0 0.973 0.956–0.990 9.155 0.002
Self-transcendenceh 1.0 1.010 0.990–1.031 1.034 0.309

Patients without PD (n = 285) Schizotypal PD (n = 9) Diagnostic testsp

Variable ORb OR 95%CI Wald x2 P Se (11%) Sp (100%) PPV (100%) NPV (97%)

Harm avoidance 1.0 1.017 0.978–1.059 0.727 0.394

Novelty seeking 1.0 0.976 0.937–1.017 1.297 0.255
Reward dependence 1.0 0.983 0.939–1.029 0.556 0.456
Persistence 1.0 1.010 0.973–1.049 0.292 0.589
Self-directedness 1.0 0.985 0.947–1.025 0.540 0.463
Cooperativeness 1.0 0.976 0.940–1.014 1.523 0.217
Self-transcendencei 1.0 1.081 1.028–1.136 9.392 0.002
ST3 (spiritual acceptance) 1.0 1.229 1.082–1.395 10.142 0.001

Patients without PD (n = 285) Narcissistic PD (n = 15) Diagnostic testsp

Variable ORb OR 95%CI Wald x2 P Se (14%) Sp (99%) PPV (67%) NPV (96%)

Harm avoidancej 1.0 1.003 0.971–1.036 0.034 0.855

Novelty seekingj 1.0 1.036 1.003–1.070 4.664 0.031
Reward dependencek 1.0 0.975 0.939–1.012 1.767 0.184
Persistencek 1.0 1.032 1.000–1.064 3.901 0.048
Self-directednessk 1.0 0.947 0.916–0.978 10.596 0.001
SD4 (self-acceptance) 1.0 0.878 0.820–0.941 13.564 < 0.001
Cooperativenessj 1.0 0.953 0.924–0.983 9.404 0.002
C5 (pure-hearted) 1.0 0.828 0.734–0.935 9.341 0.002
Self-transcendencek 1.0 1.011 0.975–1.047 0.331 0.565

Patients without PD (n = 285) Borderline PD (n = 111) Diagnostic testsp

b 2
Variable OR OR 95%CI Wald x P Se (41%) Sp (92%) PPV (66%) NPV (80%)

l
Harm avoidance 1.0 1.027 1.010–1.044 10.269 0.001
HA1 (anticipatory worry) 1.0 1.112 1.058–1.169 17.518 < 0.001
HA4 (fatigability and asthenia) 1.0 1.088 1.033–1.146 10.267 0.001
Novelty seekingl 1.0 1.002 0.987–1.018 0.081 0.775
Reward dependencem 1.0 0.994 0.976–1.013 0.371 0.542
Persistencem 1.0 0.988 0.974–1.002 2.770 0.096
P2 (work hardened) 1.0 0.923 0.876–0.976 9.168 0.002
Self-directednessl 1.0 0.959 0.943–0.975 23.656 < 0.001
490 P. Jylhä et al. / European Psychiatry 28 (2013) 483–491

Table 5 (Continued )

Patients without PD (n = 285) Borderline PD (n = 111) Diagnostic testsp

b 2
Variable OR OR 95%CI Wald x P Se (41%) Sp (92%) PPV (66%) NPV (80%)

SD1 (responsibility) 1.0 0.860 0.803–0.921 18.470 < 0.001

SD3 (resourcefulness) 1.0 0.875 0.810–0.944 11.768 0.001
SD5 (congruent second nature) 1.0 0.907 0.862–0.954 14.198 < 0.001
Cooperativenessm 1.0 0.967 0.951–0.983 15.189 < 0.001
C3 (helpfulness) 1.0 0.871 0.812–0.933 15.323 < 0.001
C4 (compassion) 1.0 0.921 0.879–0.965 11.885 0.001
Self-transcendencem 1.0 1.017 0.999–1.034 3.519 0.061

Patients without PD (n = 285) Antisocial PD (n = 35) Diagnostic testsp

Variable ORb OR 95%CI Wald x2 P Se (41%) Sp (98%) PPV (68%) NPV (93%)

Harm avoidancem 1.0 1.036 1.004–1.070 4.812 0.028

Novelty seekingn 1.0 1.042 1.011–1.074 7.283 0.007
NS2 (impulsiveness) 1.0 1.145 1.049–1.249 9.180 0.002
NS3 (extravagance) 1.0 1.155 1.058–1.261 10.431 0.001
Reward dependenceo 1.0 0.980 0.950–1.011 1.670 0.196
Persistenceo 1.0 0.955 0.928–0.983 9.686 0.002
P2 (work hardened) 1.0 0.858 0.783–0.941 10.599 0.001
Self-directednessn 1.0 0.952 0.926–0.979 11.752 0.001
SD1 (responsibility) 1.0 0.830 0.741–0.931 10.149 0.001
SD2 (purposefulness) 1.0 0.846 0.758–0.944 8.927 0.003
SD3 (resourcefulness) 1.0 0.784 0.686–0.897 12.660 < 0.001
SD5 (congruent second nature) 1.0 0.864 0.794–0.940 11.506 0.001
Cooperativenesso 1.0 0.970 0.945–0.994 5.730 0.017
Self-transcendenceo 1.0 1.023 0.994–1.052 2.360 0.125

Se: sensitivity; Sp: specificity; PPV: positive predictive value; NPV: negative predictive value. Statistically significant values after Bonferroni correction are in boldface.
a
For subscales, only statistically significant findings are shown in the table. Variables are entered separately into the model and adjusted for possible confounding
sociodemographic factors (age, gender, education, work status, marital status), and scores of the Hamilton Depression Rating Scale and Beck Anxiety Inventory.
b
Reference group
c
At index interview, when scores on the Hamilton Depression Rating Scale were at a minimum (Jorvi Bipolar Study), or at the 5-year follow-up (Vantaa Depression Study)
or at baseline (Primary Care Vantaa Depression Study)
d
Missing data 10/85, 38/285.
e
Missing data 10/85, 35/285.
f
Missing data 10/85, 35/285.
g
Missing data 6/63, 35/285.
h
Missing data 6/63, 35/285.
i
Missing data 35/285.
j
Missing data 1/15, 35/285.
k
Missing data 1/15, 35/285.
l
Missing data 11/111, 35/285.
m
Missing data 10/111, 35/285.
n
Missing data 2/35, 35/285.
o
Missing data 2/35, 35/285.
p
From a logistic regression model, where all TCI dimensions served as independent variables and whether or not having a specific PD diagnosis served as a dependent
variable.

studies [15,22,36]. In line with some [1,35,36] but not all [22]
studies and contrary to our hypothesis, high RD was not associated
with avoidant PD, whereas, as hypothesized, low RD was
associated (as a trend) with having an obsessive-compulsive PD.
Moreover, high P4 (perfectionist) was associated with obsessive-
compulsive PD, supporting a previous finding [35] that high
persistence predicts obsessive-compulsive traits, especially when
coupled with high HA. Altogether, among cluster C PDs, our study
confirmed four of five predicted relationships between tempera-
ment dimensions and PDs.
In accordance with our hypothesis, cluster B PD patients scored
higher on NS than patients without any PD. High NS was associated
with having an antisocial PD, and, as a trend, with having a
narcissistic PD. Moreover, NS was found to correlate positively
with the number of borderline PD symptoms. These findings are
also in line with former studies [35,36]. As expected, high HA was
associated with having a borderline PD, but contrary to our
hypothesis low HA was not associated with having an antisocial
PD. Of the associations between RD and cluster B PDs, only the
negative correlation between the number of antisocial PD
symptoms and RD was in the expected direction. Overall, five of
eight relationships between temperament dimensions and diag-
nosis or symptoms of cluster B PDs were in the predicted direction.
Cloninger’s original hypothesis gave no predictions for
temperament and schizotypal PD. However, we expected to find
a negative relationship between schizotypal PD and RD scores,
given that a low RD has been described as the main temperament
feature in cluster A PDs [36]. Contrary to this expectation, we
found no significant association between RD and schizotypal PD,
possibly due to the small number of schizotypal cases in our
study.
The logistic regression models estimated from the data
correctly predicted the specific PD diagnosis to a varying
degree. Although the models’ specificity in identifying
patients without a specific PD was high, the sensitivity in
predicting those with a specific PD was low. Thus, TCI
dimensions may not capture all relevant personality traits of
the DSM-IV PDs [24], particularly symptom-like behaviour may
remain uncovered.
In conclusion, among mood disorder patients, the medium-
term temporal stability of Cloninger’s temperament and character
dimensions appeared to be good. As hypothesized, the character
scores differed between PD and non-PD patients, but the
temperament scores only to some degree between specific PDs.
Overall, the TCI dimensions capture only a portion of the
differences between PD and non-PD patients.
 P. Jylhä et al. / European Psychiatry 28 (2013) 483–491
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
Acknowledgements
This work was supported by research funding from the
Academy of Finland and the Department of Psychiatry at Helsinki
University Central Hospital.
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