Journal of Affective Disorders 100 (2007) 13 21

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Special research report

Exploring the margins of the bipolar spectrum: Temperamental

features of the typus melancholicus
Giovanni Stanghellini a,, Andrea Raballo b
b

a
Department of Biomedical Sciences, University of Chieti, Italy
Psychiatric Intensive Care Unit, Department of Mental Health, AUSL Reggio Emilia, Italy

Received 8 August 2006; accepted 12 September 2006

Available online 16 January 2007

Abstract
Background: Both the melancholic type of personality (TM) and the concept of temperament offer promising insights for the
phenotypic characterization of mood-spectrum vulnerability. This research challenges the theoretical hiatus between the two
psychopathological paradigms the phenomenological and the neo-Kraepelinian by means of an empirically-based approach.
Method: Temperamental features were assessed through the Semi-structured Affective Temperament Interview (TEMPS-I) in an
outpatient population of 116 clinically stable, euthymic subjects who suffered from a DSM IV major depressive disorder,
previously enrolled for a study on the characteristics of major/unipolar depressive episode. The sample was subsequently evaluated
and dichotomized according to the Criteria for Typus Melancholicus (CTM).
Results: The TM subjects exhibited statistically significant differences in the temperamental profile as compared to non-TMs
(NTM). A specific association between TM and hyperthymic temperament (HT) was confirmed by binary logistic regression
analysis, suggesting that the phenomenological distinction TM vs. NTM is supported by different predisposing Kraepelinian
fundamental states.
Limitation and conclusions: Although it is uncertain whether the findings would generalize outside the Italian culture, they
nonetheless delineate a strong aggregation between TM and hyperthymic temperament, indicating that (1) an integrative neoKraepelinian/phenomenological cooperative model is warranted to tap the complexity of the phenotypic diathesis for mooddisorders, and (2) the hyperthymic melancholic type of personality rests on the margins of the bipolar spectrum.
The main limitation of this study is that it enrolled a selected outpatient volunteer sample. A large scale study in general
population is needed to confirm the hypothesis of a strong link between TM and HT and to shed light on the causes and meanings
of this association.
2006 Elsevier B.V. All rights reserved.
Keywords: Bipolar spectrum; Temperament; TEMPS; Phenomenology; Melancholic type; Pre-morbid vulnerability

1. Introduction
Although much has been published about the clinical
features of pre-morbid personality traits of mood
Corresponding author. Viale Don Minzoni 45, 50129 Florence,
Italy. Tel.: +39 347 3790707.
E-mail address: giostan@libero.it (G. Stanghellini).
0165-0327/$ - see front matter 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2006.09.039

disorders, there has been a comparative paucity of

research focusing on the combination between the
recently revitalized neo-Kraepelinan conceptualization
of temperaments (Akiskal et al., 1998, 2005a,b) and the
phenomenologically-inspired notion of the melancholic
type of personality (Tellenbach, 1961; Kraus, 1977;
Tatossian, 1979; Stanghellini, 2004). This integrative
effort appears especially promising in the view of the

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G. Stanghellini, A. Raballo / Journal of Affective Disorders 100 (2007) 1321

growing evidence supporting the continuity among

mood disorders (Akiskal and Benazzi, 2006).
1.1. The spectral background
Modern concepts of temperament, incorporating
Kraepelin (1921) and Kretschmer (1936) models of the
continuum between pre-morbid traits and full-blown
mood disorders, offer an instructive, clinically coherent
background to target affective liability (Akiskal et al.,
1977; Akiskal, 1981, 1983, 1996, 2002; Akiskal and
Akiskal, 2005a,b; Placidi et al., 1998a,b). Consensually, a
new spectrum paradigm is emerging in the research
literature and in clinical practice (Akiskal, 2002, 2005)
together with the rebirth of attention to the concept of
temperament (Akiskal, 1996, 2005). By the notion of
bipolar spectrum Akiskal (1983) conceptualised mood
disorders as a clinical continuum extending from subclinical manifestations to overt bipolar I disorder and
encompassing major and minor depression, dysthymia,
cyclothymic disorder, and bipolar II disorder, and beyond
(Akiskal, 2002, 2003; Akiskal and Pinto, 1999; Akiskal
et al., 2000, 2003a,b). Such heuristic paradigm a partial
return to the Kraepelinian (Kraepelin, 1921) broad
concept of manic-depressive insanity is rooted in the
descriptive clinical tradition and is validated by a new
wave of epidemiologic studies demonstrating the high
prevalence of sub-threshold cases, familial aggregation
studies, high-risk offspring studies, analysis of monozygotic discordance, and molecular linkage studies
(Akiskal, 2002, 2003). Furthermore, such evolving
reformulation of the subclassification of mood disorders
has substantially broadened the boundaries of bipolarity
and encroaches into the terrain of so-called unipolar
anxious depressions (Akiskal, 1983, 2002; Akiskal et al.,
2003a; Perugi et al., 1998; Perugi and Akiskal, 2002;
Benazzi, 2006). Even the hyperthymic type involved at
the edges of the bipolar spectrum has been proposed
(Akiskal and Mallya, 1987; Akiskal and Pinto, 1999).
This nosological expansion of bipolarity has major
implications for assessment methodology, clinical approach and public health, and directly impacts on the
conceptualization of the vulnerability to mood disorders;
also, it challenges the taken-for-granted boundaries
between norm and pathology.
However, besides the notion of Kraepelinian temperaments (conceived as different modalities of subclinical long-term traits of mood disorders), other
models based on personality were proposed in European
psychopathology to explore mood liability, i.e. the
manic type (von Zerssen and Possl, 1990; Possl and von
Zerssen, 1990; von Zerssen et al., 1994) and the

melancholic type of personality (typus melancholicus = TM). The latter has been specifically addressed
by phenomenological psychopathology as the personality structure predisposing to major/unipolar depression
(Tellenbach, 1961; Kraus, 1977, 1996; Mundt et al.,
1997; Stanghellini and Mundt, 1997).
1.2. The melancholic type of personality: the crucial
challenge of unipolar affective vulnerability
The melancholic type of personality (typus melancholicus = TM) is, in Continental European (Tellenbach,
1961; Kraus, 1977) and Japanese (Shimoda, 1950;
Shinfuku and Ihda, 1969) psychopathological traditions,
the pre-morbid personality of unipolar/major depressives.
In the area of phenomenologically-oriented psychopathology it is considered one of the most fundamental
contribution to the understanding of the depressives' premorbid behaviours, world-view, precipitating situations
and acute clinical pictures (Stanghellini and Mundt,
1997). However insightful, empirically testable and
therapeutically valuable (Mundt et al., 1996, 1997;
Stanghellini et al., 2006) it can be, the TM construct has
not been adopted by current diagnostic manuals and is still
scarcely known by clinicians.
The TM's style of behaviour is impressive for its
over-normality, extreme social adjustment and conformism (for reviews see Stanghellini and Mundt, 1997; von
Zerssen, 2002). TMs are conventionally well-behaved
and dependent on the judgement of the others. Their
actions are chiefly aimed at fulfilling the interests of the
environment, to achieve harmony in relationships by
rigidly preserving the well-established social roles and
hierarchies regulating interpersonal life, and to avoid
guilt feelings and guilt attribution. The core-properties
of the TMs are orderliness, conscientiousness, hypernomia/heteronomia, and intolerance of ambiguity
(Stanghellini and Mundt, 1997; Stanghellini and
Bertelli, 2000, 2005).
Orderliness can be defined as the fixation in harmony
in interpersonal relationships. This applies especially to
well-established social roles and hierarchies regulating
interpersonal relations. Such a fixation entails an
exaggerated need for appreciation by others. Conscientiousness can be defined as the commitment to prevent
guilt-attributions and guilt-feelings. TMs' behaviours are
determined by the need to preserve their own role identity
by reducing all possible causes of social conflict
(agreeableness). Since interpersonal conflicts may jeopardise orderliness, fulfilling the expectations of others is
often the best policy for TMs. Hypernomia can be
defined as exaggerated norm adaptation and rigidity.

G. Stanghellini, A. Raballo / Journal of Affective Disorders 100 (2007) 1321

Heteronomia complements the concept of hypernomia

by describing the TMs' exaggerated receptiveness of
social roles and norms. TMs tend to statically conform to
standardised social roles and norms in order to avoid
conflicts and prevent guilt attributions and guilt feelings.
Intolerance of ambiguity can be defined as the incapacity to emotionally and cognitively perceive opposite
characteristics in the same object or person. Intolerance of
ambiguity allows TMs to experience only those features
( e.g. in social situations) which confirm the preconstituted and generally idealised images of themselves
and of others.
1.3. Aim of the study
This research is directed to the core of traditional
unipolar vs. bipolar dichotomy. The assessment of the
temperamental features of a sample of persons who
suffered from major/unipolar depressive disorder and
meet the criteria for TM personality could corroborate
Akiskal's hypothesis of the existence of a rich extension
of attenuated bipolarity into, among others, the
conventional territories of major depressive disorders,
anxiety states, cluster B personality disorders, and the
sub-threshold realm in the community (Akiskal, 2003).
In detail, this study addresses the relationship
between a given kind of personality structure, called
the melancholic type of personality, and its temperamental fundamental state'. Operatively, we used the
TEMPS-I to examine temperamental differences between TM vs. non-TM (i.e. NTM) outpatients with
major/unipolar depression. According to their essential
features ( i.e. orderliness, conscientiousness, hyper/
heteronomia, and intolerance of ambiguity) which
require a basal hyperactive, eager and solicitous attitude,
the TM subjects are expected to show higher scores in
hyperthymia than NTM major/unipolar depressive
patients, but at the same time to show specific personality characteristics that do not entirely overlap with the
construct of hyperthymic temperament.
2. Subjects and methods
2.1. Subjects
The present research utilized data from a previous
protocol, which recruited individuals during a three year
period (20012003) among the outpatients who applied
to the University Mental Health Outpatient Clinic
(Florence) for mood disorders.
The study population was composed by 116 physically healthy subjects (33 men and 83 women; mean age

15

49.92 14.07 years; sex ratio: 1 male each 2.5 females),

who met DSM-IV (APA, 1994) and ICD-10 (WHO,
1992) criteria for major/unipolar depressive episode
(about the 18% of the sample (n = 21), had their first
depressive episode) and had no anamnestic evidence for
bipolar spectrum disorders (i.e. Bipolar type I, Bipolar
type II, family history of mania, and antidepressantassociated hypomania) and no comorbid psychiatric
diagnosis on DSM-IV axis I. Detailed sociodemographic
and psychopathologic description of the final sample is
presented in Stanghellini et al. (2006).
Each volunteer outpatient who was enrolled for the
previous data collection (which included the Structured
Clinical Interview for DSM-IV Axis I Disorders-Clinician
Version (SCID-CV, First et al., 1997), the Association for
Methodology and Documentation in Psychiatry (AMDP)
system (AMDP, 1979, 1995) and the Criteria for Typus
Melancholicus (CTM) (Stanghellini and Bertelli, 2000,
2005), contextually accepted to be assessed with
TEMPS-I. Written informed consent was collected
individually before the whole, comprehensive data
collection (Stanghellini et al., 2006).
2.2. Instruments and procedures
2.2.1. TEMPS-I
The Italian semi-structured interview version of the
Temperament Evaluation of Memphis, Pisa, and San
Diego (TEMPS-I) was used for the temperamental
assessment.
Originally developed in Memphis (Akiskal and
Mallya, 1987; Akiskal and Akiskal, 2005a,b). The
interview was tested not only in Pisa, but also in Paris
and San Diego, and has shown excellent psychometric
properties (Akiskal et al., 1998; Placidi et al., 1998a,b).
All the participants were evaluated by means of the
TEMPS-I semi-structured format for Hyperthymic (HT,
7 items), Depressive (DT, 7 items), Cyclothymic (CT,
10 items) and Irritable (IT, 8 items) temperaments.
At the start of the interview, each subject was
instructed to answer by considering his/her habitual self
over a time span extending as far as he/she remembered.
As a further caution, the items were randomized in order
to prevent participants from answering all subsequent
questions on a given scale in the same way.
2.2.2. CTM
The version of the Criteria for Typus Melancholicus
(CTM) used in the present study is the one proposed and
validated by Stanghellini and Bertelli (2000, 2005) which
condenses clear, valid, and synthetic criteria according to
pre-existing conceptual analyses of the TM (Stanghellini

16

G. Stanghellini, A. Raballo / Journal of Affective Disorders 100 (2007) 1321

Table 1
Internal consistency for the four temperament scales

Hyperthymic temperament
Depressive temperament
Depressive temperament [c]
Cyclothymic temperament
Irritable temperament

Valid number

Mean

SD

Cronbach alpha

ICC 95%CI

Item number

116
116
116
116
116

2.94
2.36
1.58
0.93
0.43

2.231
1.779
1.729
2.442
1.167

0.82
0.70
0.76
0.96
0.81

0.760.87
0.600.78
0.680.82
0.940.97
0.750.87

7
7
6
10
8

ICC = intraclass correlation coefficient; CI = confidence interval.

[c] = DT without item Dep 5 to enhance internal consistency.

and Mundt, 1997). The CTM was specifically designed to

capture essential features of the TM's social behaviour
from the angle of its motivations and has shown good
psychometric properties, especially diagnostic power,
reliability, and internal consistency (Stanghellini and
Bertelli, 2005). CTM includes a definition, a concise
description and some illustrative first-person sentences
gathered from patients' interviews (see Stanghellini et al.,
2006). Each of the four TM characteristics (namely: orderliness, conscientiousness, hyper/heteronomia, intolerance
of ambiguity) is scored either 0 (absent) or 1 (present).
Participants were classified as TM if three criteria out of the
four CTM were satisfied.
For each patient TEMPS-I and the CTM assessment
were performed independently by reciprocally-blind
clinical raters ( i.e. those who evaluated CTM were blind
of the result of TEMPS-I and vice versa) at the end of
the depressive episode.
The latter was operatively defined as at least four
week absence of any clinically relevant (i.e. causing
socio-functional deterioration) symptom of those included in the DSM-IV and ICD-10 diagnostic criteria for
major/unipolar depressive episode (see Stanghellini

et al., 2006 for details). Such symptomatic remission

(which was achieved on an average period of 20.7
18.6 weeks after the acute episode) was required to
minimize the potential confounding effect of concomitant mood psychopathology in the temperament and
personality assessment.
The inter-rater reliability of the four temperaments
was assessed in a subsample composed by the first 30
enrolled participants. The kappa value, between the two
blind, independent raters for the factorial scores of HT,
DT, CT and IT temperaments were 0.93, 0.84, 0.94 and
0.95, respectively. The CTM assessment was performed
by the same raters who participated to the CTM
validation protocol (see Stanghellini and Bertelli,
2005, for details and inter-rater reliability).
2.3. Statistical analyses
The internal consistency coefficients for the 4 TEMPSI scales were calculated before sample analysis. To
explore potential sampling biases due to sex distribution
(m/f ratio = 1/2.5) a preliminary male vs. female comparison was performed for mean duration of the illness,

Table 2
Background characteristics of the sample

Duration of illness
Number of episodes
Hyperthymic temperament
Depressive temperament
Depressive temperament [c]
Cyclothymic temperament
Irritable temperament
CTM distribution

Whole sample

Males (33)

Mean

SD

Mean

SD

Mean

SD

Test

24.91
3.69
2.94
2.36
1.58
0.93
0.43
NTM
n = 36
31%

14.09
1.90
2.23
1.78
1.73
2.44
1.17
TM
n = 80
69%

27.12
3.94
2.52
2.77
2.00
0.28
044
NTM
n=9
27.3%

11.34
1.68
2.38
1.76
1.77
1.40
1.,08
TM
n = 24
72.7%

24.02
3.59
3.12
2.19
1.40
1.15
0.42
NTM
n = 27
32.5%

15.02
1.98
2.16
1.77
1.69
2.69
1.20
TM
n = 56
67.5%

0.888 a
0.815 a
1.150 a
1.574 a
1.563 a
1.563 a
1.720 a
0.305 b

0.374
0.415
0.250
0.115
0.118
0.118
0.085
0.581

TM: typus melancholicus, NTM: non-typus melancholicus.

[c] = DT without item Dep 5 to enhance internal consistency.
a
MannWhitney U test.
b
Chi-square test.

Females (83)

Statistics

G. Stanghellini, A. Raballo / Journal of Affective Disorders 100 (2007) 1321

Table 3
TEMPS-I subscale scores across the samples: NTM vs. TM
NTM
Mean SD
Hyperthymic
temperament
Depressive
temperament
Depressive
temperament [c]
Cyclothymic
temperament
Irritable temperament

Statistics a

TM
Mean SD

0.59

1.32 3.82

1.83 6.61 b0.0001

2.14

2.30 2.44

1.56 1.54

0.124

1.96

2.12 1.44

1.56 0.54

0.591

2.82

3.48 0.15

1.21 5.54 b0.0001

1.00

1.33 0.19

1.01 4.21 b0.0001

TM: typus melancholicus, NTM: non-typus melancholicus.

[c] = DT without item Dep 5 to enhance internal consistency.
a
MannWhitney U test.

number of depressive episodes, TEMPS-I subscores and

TM prevalence. Then, the sample was subdivided
according to CTM in NTM vs. TM subgroups.
Differences between groups were compared by
means of the MannWithney U test contrasting HT,
DT, CT and IT dimensional scores. Binary Logistic
Regression (outcome variable = NTM vs. TM; predictors = 4 neo-Kraepelinian temperaments + number of
depressive episodes) was finally performed to facilitate
a clinically-pertinent parsimonious interpretation of the
results, by finding the best predictive independent
variables set and evaluating its prediction accuracy.
We used the SPSS as our statistical package for the
foregoing analyses.
3. Results
3.1. TEMPS-I internal consistency in the clinical sample
The Cronbach's analysis confirmed very high internal
consistency for HT, CT and IT which substantially
overlapped those found in non-clinical samples (Placidi

17

et al., 1998a). DT revealed a slightly lower internal

consistency, mainly due to item 5 (i.e. Dep 5: Conscientious or self-disciplining) moderate degrading tendency (0.70 vs. 0.76 if item 5 was not included in the DT
subscale) (Table 1). However, to preserve the integrity of
the original item composition of DT, subsequent analyses
were performed with the standard 7 item subscore.
3.2. Background characteristics
General sociodemographic characteristics of the
sample have been previously reported (Stanghellini
et al., 2006). Descriptive statistics of duration of the
illness, average number of episodes, TEMPS-I scores
and CTM distribution are presented in Table 2. All these
parameters were independent of gender.
3.3. TEMPS-I temperaments in NTM vs. TM
A comparison of the TEMPS-I subscores between the
two groups (dichotomized according to CTM, Table 3)
showed that TM had higher HT than NTM, whereas CT
and IT levels resulted significantly higher in NTM. No
differences were found in DT. These findings remained
after adjustment for age and gender and were controlled
substituting DT (7 items, alpha = 0.70) with DT minus
item Dep 5 (6 items, alpha = 0.76).
3.4. Neo-Kraepelinian predictors of NTM vs. TM
The binary logistic regression, with TEMPS-I subscores as independent variables and NTM vs. TM
categorisation as the dependent variable appears in
Table 4. The multivariate regression model, which was
adjusted for the number of depressive episodes, revealed
that only high score on HT was predictive of TM. A
similar result emerged when DT was substituted with
DT minus item Dep 5 (not shown in Table 4).

Table 4
Temperamental predictors of NTM vs. TM

Hyperthymic temperament
Depressive temperament
Cyclothymic temperament
Irritable temperament
Number of episodes

S.E.

Wald

df

Odds ratio

OR 95% CI

1.98
0.64
0.20
0.10
0.18

0.55
0.38
0.28
0.38
0.25

12.82
2.85
0.50
0.07
0.50

1
1
1
1
1

b0.00001
0.091
0.479
0.795
0.481

7.28
1.90
0.82
0.91
1.19

(2.4621.56)
(0.903.99)
(0.471.43)
(0.431.92)
(0.731.94)

Model parameters
R-square
2 log likelihood
Correctly classified, %
OR = odds ratio; CI = confidence interval.

0.81
34.47
94.7

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G. Stanghellini, A. Raballo / Journal of Affective Disorders 100 (2007) 1321

4. Discussion
According to Jaspers (1923), temperament can be
defined as the constitutional substratum of personality, i.e.
an assemblage of habits and skills among which maybe the
best validated are emotionality, activity and sociability
(Rutter, 1987; Jouvent and Widlocher, 1994; Cloninger,
1994), while personality refers to a constellation of
attitudes towards reality, coping strategies, mechanisms of
defence and a set of moral values. This study, that brings
together the phenomenological with the clinical-descriptive
neo-Kraepelinian paradigms, addresses the relationship
between a given kind of personality structure, called the
melancholic type of personality, and its temperamental
fundamental state'. Both affective temperaments and the
melancholic type of personality have long been discussed
as pre-morbid personality traits of mood disorders
(Akiskal, 1996; Mundt et al., 1997; Stanghellini et al.,
2006). Thus, it is desirable to combine TEMPS-I and CTM
insights to better characterize the possible structure of
mood vulnerability from a combined phenotype perspective the neo-Kraepelinian description of fundamental
states and the phenomenological characterization of an
anthropological structure. Although the two constructs
(temperaments and the melancholic type of personality)
rest on two different theoretical levels, they however
showed a non-random, clinically plausible pattern of
aggregation at least between hyperthymic temperament
and TM.
In our sample, the phenomenologically based distinction between NTM and TM personality, which was
previously shown to subtend specific clinical aggregation
of depressive symptoms (Stanghellini et al., 2006), seems
corroborated by rather different temperamental profiles.
Whereas depressive temperament was equivalently
distributed among the subsamples, cyclothymic and
irritable traits were characteristic of NTM. On the
contrary, TMs showed significantly higher hyperthymic
traits as compared to NTM outpatients.
Thus, a provocative and apparently counter-intuitive
evidence emerging from our data is that a relevant
allegedly predisposing vector of bipolarity, i.e.
hyperthymic temperament, is a discriminant trait feature
of the typus melancholicus. Such association is coherent
with both idiographical clinical observation by Kretschmer (1936), Lange (1926), Arieti (1959) and Tellenbach
(1961), who described hyperactive, eager and alacritous
behaviours in people vulnerable to major depression, and
with empirical research into the temperament of major
depressives, demonstrating that a significant minority of
major depressive pseudo-unipolar breakdowns arise
from a hyperthymic baseline characterized by patterns

including highly adaptive extraverted traits, high

functioning, tirelessness, enormous capacity of work,
work-addiction, as well as affability, assertiveness, ad
denial of distress and of personal limitations (Perugi
et al., 1990; Akiskal, 1994, 1996; Cassano et al., 1999).
This advocates the hypothesis that, from the angle of
his hyperthymic temperamental characteristics, the TM
may be seen as another variant of the soft bipolar
spectrum, next to cyclothymicanxioussensitive temperamental type recently proposed by Perugi and
Akiskal (2002). The latter is characterized by the
coexistence of an affective cyclothymic temperamental
dysregulation with concomitant anxiousdependent
traits and subsumes a set of conditions characterized
by mood reactivity, interpersonal sensitivity, enhanced
liability to mood, anxiety and impulse control disorders.
In contrast to the cyclothymicanxioussensitive type
who shows mood lability as its core feature, impulse
dyscontrol and bipolar II disorder; the hyperthymic
melancholic type described here is characterized by
hyperactivity, overinvolvement, sociability (temperamental traits), conscientiousness, orderliness, hypernomia/heteronomia and intolerance of cognitive and
emotional ambiguity (personality traits), as well as by
a characteristic sub-syndromal aggregation of depressive symptoms including lack of vital drive, feelings of
guilt, affectivevital anesthesia and depressionanxiety
(clinical state-dependent features).
Thus the net effect of the broadened boundaries of
bipolarity could be, beside the encroachment into the
terrain of so-called unipolar anxious depressions
(Akiskal, 1983, 2002), a reformulation of the traditional
view of unipolar diathesis.
4.1. Limitations
Albeit the background sociodemographic characteristics of our sample are comparable to that of other
studies addressing pre-morbid personality in depressive
patients, some cautionary notes about the generalizability of the results might be pertinent.
First, the methodology of our study cannot resolve the
question whether the affective temperaments have any
direct causal relation with TM or NTM pre-morbid
personality. Prospective studies of the affective temperaments coupled with multidimensional assessment of the
TM are needed to resolve this question. Indeed, if affective
temperaments represent sub-affective trait manifestations
of affective disorders, such sub-threshold affective
manifestation would be inseparably woven with personality traits (Akiskal, 1981; Hirschfeld et al., 1989;
Widiger, 1989). Only a more fine-grained, longitudinal

G. Stanghellini, A. Raballo / Journal of Affective Disorders 100 (2007) 1321

evaluation of personality could shed light on the nature of

the strong association between HT and TM, e.g. on issues
of onthogenetic priority.
Furthermore, such issue would benefit of a large,
general-population based survey looking for dimensional
trait cosegregation of the TM and HT. Our sample
consisted of volunteer outpatients only, thus the results are
to be restricted only to those TM who seek for specialist
support after experiencing a major depressive episode.
Even if patients were assessed once clinical remission was achieved and enquired about their habits over a
life-long time span, it is not possible to exclude that
intermittent low-grade (putatively prodromal) subdepressive symptoms might have interfered with
TEMPS-I and CTM evaluation.
Finally, it must be acknowledged that the empirical
observation of a strong connection between TM and a
given temperament in a clinical population is not theoretically explicative by itself: it leaves still unsolved the
rather cardinal question of whether TM subjects are always
HT or only those who would develop a depressive episode.
Furthermore, if according to Kraepelin (1921), the affective temperaments represent protracted attenuated phases
of mood disorders that could exist on their own, precede, or
follow affective episodes, is TM to be interpreted as a
superimposed adaptive structure to enhanced basal HT, or
is HT a necessary substrate for TM to unfold?
5. Conclusion
Judging from the foregoing discussion on the mood
spectrum, this study is significant in confirming the
heuristic power of neo-Kraepelinian approach with
regard to phenomenologically-oriented methods of
exploration of personality, as in the case of the
melancholic type personality, and vice versa.
The strong aggregation between TM and hyperthymic
temperament highlights the need for a comprehensive
neo-Kraepelinian/phenomenological cooperative model
to address the complexity of the phenotypic diathesis for
mood disorders. The search for such robust predisposing
phenotypes for mood spectrum has profound implications for the heuristic conception of bipolar spectrum
(Akiskal, 1983, 2002): our findings reinforce the case for
an evolving reformulation of the bipolar spectrum model
incorporating phenomenological constructs like the TM
personality within the margins of the soft spectrum.
Now that the temperamental characteristics can be
reliably explored in the general population of juvenile and
young adult subjects by means of the self-rated instrument
TEMPS-A (Akiskal et al., 2005a,b), we are in the final
stages of testing an auto-questionnaire version of the

19

CTM, which would be useful for population studies and

genetic epidemiology. Given the high loading of familial
affective disorders in the affective temperaments under
consideration Akiskal, 1995, 2005, research on the
fundamental neurobiology of mood disorders would
benefit from inclusion of CTM-based personality measures that might contribute to shed light on the interplay
between biological temperamental traits and the motivational features of personality of people at the borders of
the bipolar spectrum. This would allow further validation
on the basis of phenomenology, comorbidity, epidemiology, course, family history, twin studies, molecular
genetics and an evolutionary perspective of the association between TM and certain temperamental configurations like the hyperthymic temperament.
Acknowledgement
The authors would like to thank Marco Bertelli, MD
for his precious help in collecting the research data.
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