DEPRESSED OR “JUST”
SAD? DRAWING THE LINE
BETWEEN PERSONALITY AND
ILLNESS
David C. Rettew, M.D.
Associate P rofe ssor of P syc hiatr y and Pe d iatrics
Dire ctor, Pe d iatric P syc hiatr y Clinic
P rogram Dire ctor, Child P syc hiatr y Fellow ship
Unive r sity of Ve rmont, Colle ge of M e d icine
[email protected]
Blogs
http://blog.uvm.edu/drettew
http://www.psychologytoday.com/
blog/abcs-child-psychiatry
DISCLOSURES OF POTENTIAL
CONFLICTS
Source
Research
Funding
Advisor/
Consultant
Employee
Speakers’
Bureau
Norton &
Norton
NIMH
Books,
Intellectual
Property
X
X
Psychology
Today
Book on temperament by WW Norton
X
In-kind
Services
(example:
travel)
Stock or
Equity
Honorarium
or expenses
for this
presentation
or meeting
IT’S NOT A DISEASE, IT IS “JUST” HIS
PERSONALIT Y
OBJECTIVES
Brief review of temperament
Research on associations and
mechanisms of
temperament/psychopathology relations
Practical implications in clinical practice
WHAT IS TEMPERAMENT?
Individual differences in basic behavioral response
styles or dispositional traits (Nigg 2006)
Have the following qualities…
Appear early, moderately stable, genetic influence
CHILD TEMPERAMENTAL TRAITS
(CHESS AND THOMAS)
Activity Level
Response Intensity
Rhythmicity
Mood
Approach-Withdrawal Distractibility
Adaptability
Attention
Response Threshold Span/Persistence
3 Types: Difficult, Easy, Slow to Warm Up
GOODNESS OF FIT THEORY
MAJOR DIMENSIONS
Cloninger
 Novelty Seeking
 Harm Avoidance
 Reward Dependence
 Persistence
 Cooperativeness
 Self-Directedness
 Self-Transcendence
Kagan
 Behavioral Inhibition
 Behavioral Disinhibition
The Big Five (Costa and McCrae)
 Neuroticism
 Extraversion
 Openness
 Agreeableness
 Conscientiousness
Rothbart
 Negative Affectivity
 Extraversion/Surgency
 Effortful Control
MAJOR CATEGORIES
Negative
Emotionality
Extraversion
Moderate
Confident
Anxious
Agitated
Mellow
Rettew, Child Temperament, 2013
Regulation
THE “YET” SYNDROME
Positive
Negative
Extraversion
Sense of Adventure
Spontaneous
Hot
temper
YET
Disorderly
Negative
Affectivity
Caution
Sensitivity
Worried
YET
Unassertive
Sociability
Sympathetic
Warm
Needy
YET Conforming
TEMPERAMENT STABILIT Y
(JANSON ET AL., 2008)
GENETIC ARCHITECTURE OF NEUROTICISM
RETTEW ET AL., T WIN RESEARCH, 2006
41%
59%
Genetics
Unsh Env
 Study of 3301 adolescent twins
(mean age 15.5)
 Indications for different genes
between girls and boys
 Adolescent extraversion
influenced by non-additive
genetics (31-33%), additive
genetics (20-23%) and unshared
environment (46-48%). Additive
genetics increased with age
TEMPERAMENT IN THE BRAIN
( P E ZAWAS E T A L . , 2 0 0 5 )
Feedback loop between Subgenual ACC & Amygdala
Less in s individuals
Explains about 30% variance in Harm Avoidance
scores
BOUNDARIES OF PSYCHOPATHOLOGY
Disorder 1
Disorder
Trait
Disorder 2
TEMPERAMENT AND PSYCHOPATHOLOGY
HISTORY IN ONE SLIDE
 Part One: Freudian theory: common mechanism behind traits
and neurosis
 Part Two: Study of personality separate from psychopathology
 Part Three: Chess and Thomas bring temperament into the
world of child psychiatry
 Part Four: Medical model of psychopathology de-emphasizes
temperament
 Part Five: Research evidence gives compelling evidence of
strong/temperament relations
 Part Six (NOW!): Researchers work to understand HOW the
two domains work together
Rettew, 2013
WHERE TO DRAW THE LINE?
Polderman et al., 2007
TRAITS VERSUS ILLNESS
CONVENTIONAL WISDOM
Impairment
BUT evidence shows that impairment itself is
dimensional
For children, impairment according to whom?
Change from the usual state
BUT many disorders (e.g ADHD) not a change
and traits can also change over time
FROM IF THEY ARE RELATED…
TO HOW THEY ARE RELATED
Spectrum
Risk/Vulnerability
Common Factor
Temp
Disorder
FROM IF THEY ARE RELATED…
TO HOW THEY ARE RELATED
Pathoplastic
Scar
Temp
Disorder
OVERLAP OF TEMPERAMENT AND CHILD GAD
(RETTEW ET AL., J ANX DIS, 2006)
70
Number of Subjects
60
50
40
30
20
Current GAD
10
Yes
0
No
<2
4-6
2-4
8-10
6-8
12-14
10-12
16-18
14-16
Harm Avoidance Score
20-22
18-20
CHARACTER CUBE
C LO N I N G E R R , P E R S O N A L I T Y A N D P SYC H O PAT H O LO GY
TESTING GOODNESS OF FIT
(RETTEW ET AL, COMP PSYCH, 2006)
 Effect of parent
temperament on child
psychopathology depends
on child temperament
 High mother NS related to
child attention problems
only if child also has high
NS
ITEM OVERLAP
METHOD PROBLEM OR THEORY PROBLEM?
JTCI
CBCL
DSM-IV
True/False
None/Somewhat/Often
Yes/No
“…loses temper more
easily than other
children.” (NS)
“Temper tantrums or hot “Often loses temper”
temper” (AG)
(ODD)
“..seems to be shy with
new people.” (HA)
“Too shy or timid”
(W/D)
“Marked or persistent
fear of one or more
social situations..” (SP)
“..wouldn’t bother my
child to be alone all the
time.” (RD-r)
“Withdrawn, doesn’t get
involved with others”
(W/D)
“Neither desires nor
enjoys close
relationships..” (SPD)
JAACAP EDITORIAL, 2010
Can’t assume that scales measure what they
say just because of the title
Need to move beyond the phenotype
NEUROTICISM AND INTERNALIZING
DISORDERS (HETTEMA ET AL., AJP, 2006)
Genetic liability to
neuroticism accounts for
1/3 to 2/3 of total
genetic liability to
internalizing disorders
Disorder specific
influences most
prominent for unshared
environment
 Calculated polygenetic risk
scores from 500,000 SNPs
 “shared genetic factors
contribute to both behavioral
traits in the general population
and psychiatric disorders. …”
WHY IS THE BOUNDARY OF
PSYCHOPATHOLOGY SO CONTROVERSIAL?
 STIGMA
 More stigmatizing to “have” something or be
somewhere along a continuum?
 Unique logic in psychiatry that all of our
diagnoses need to be a really big deal
 Unique logic in psychiatry that if the cause of
a problem is big enough that we shouldn’t use
diagnostic terms
 MEDICATION OVERUSE
 Legitimate but very separate issue
LOTS OF LABELS
ONE BRAIN
Personality
“Organic” Conditions
Temperament
Personality Disorders
Axis I Disorders
CLINICAL IMPLICATIONS
Dimensional
Binary
Wellness
Ilness
Family
Individual
DIMENSIONAL PERSPECTIVE
Conceptualization and communication that an
individual possesses more or less of particular
traits rather than “having” a disease
Potentially much less stigmatizing
More hopeful to move up and down a
continuum than be “cured”
INCORPORATING WELLNESS
THE VERMONT FAMILY BASED APPROACH
 Psychiatry should be a field about behavior wellness not just
illness
 Need to assess for it in our evaluations and keep it in the
forefront of our intervention
 Nutrition
 Sleep habits
 Relationships
 Giving to others
 Sports and exercise
 Television and video games
Hudziak, 2008
BRINGING IN THE FAMILY
Behavioral assessment of the parents in
all children brought in for evaluation
Discussions of fit
Parental guidance
What does child pull out in you?
What is the natural but maybe
suboptimal response?
How can you override that?
FINAL CONCLUSIONS
 Overwhelming evidence that temperament dimensions are
strongly involved in nearly all types of psychopathology
 Mechanism of association likely different between and
likely within particular disorder-trait combinations
 Limited data on degree to which psychiatric illnesses have
unique neurobiological features that are not shared with
corresponding traits
 Full appreciation of this perspective have profound
implications on our conceptualization and approach of
people and families we see
THANK YOU
Questions???