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Abstract

Objective

To investigate whether personality traits are related to emotional symptoms (mania, hypomania, and depression) in Chinese patients with bipolar disorders.

Methods

Patients with bipolar I and II disorders, and healthy volunteers, were assessed using the Chinese Adjective Descriptors of Personality (CADP) questionnaire, Mood Disorder Questionnaire (MDQ), Hypomanic Checklist (HCL-32), and Plutchik–van Praag Depression Inventory (PVP).

Results

Seventy-three patients with bipolar I disorder, 35 with bipolar II disorder and 216 healthy controls were included. Bipolar I and II groups scored significantly higher on MDQ, HCL-32 and PVP scales than controls; the bipolar II group scored lower on the MDQ, but higher on the HCL-32 and PVP than bipolar I. In the bipolar I group, the CADP Intelligent trait (β, 0.25) predicted MDQ; Intelligent (β, −0.24), Agreeable (β, 0.22) and Emotional (β, 0.34) traits predicted PVP. In the bipolar II group, Intelligent (β, 0.22), Agreeable (β, −0.24) and Unsocial (β, 0.31) traits predicted MDQ; Intelligent (β, −0.20), Agreeable (β, −0.31) and Emotional (β, −0.26) traits predicted HCL-32.

Conclusions

Four out of five Chinese personality traits were associated with emotional symptoms in patients with bipolar I or II disorder, but displayed different associations depending on disorder type.

Keywords

Chinese culture depression hypomania mania personality trait

Introduction

Bipolar disorder types I and II, which are largely prevalent in the young population, are severe and recurrent mood disorders associated with high morbidity levels, and rank second to unipolar depression as a cause of worldwide disabilities.¹ Bipolar I and II disorders are equally prevalent across the sexes, but their clinical manifestations differ.² Bipolar II disorder has a more chronic course, mainly associated with major and minor depressive episodes and shorter inter-episodes; bipolar I is associated with one or more manic or mixed episodes. The risk of suicide appears to be particularly elevated, and the prognosis is poorer, in bipolar II compared with bipolar I disorder.^1,3

Although the prevalence of bipolar disorders in China is comparable to that in Western societies,⁴ Chinese bipolar disorders have some unique features. Understanding more about these clinical characteristics and their causes may help improve the management of patients with bipolar disorders in China. In general, Chinese patients with bipolar disorders in Taiwan display a lower comorbidity of alcohol dependence than Western patients.⁵ Also patients with bipolar disorders in Taiwan were shown to have a higher comorbidity rate with diabetes, when compared with the general population.⁶ In a Western-style mental health centre in Mainland China, younger Chinese patients with bipolar disorders tend to emphasize self-blame and individual responsibility regarding the cognitive aspects of bipolar disorder, compared with older Chinese patients.⁷

The clinical uniqueness of bipolar disorders in China might result from several factors, including the way in which the Chinese express and control emotion. A most important feature of Chinese culture is the high collectivism and high power distance,⁸ with Confucianism at the core of these values.^9,10 Chinese culture encourages individuals to ‘express joy or anger without form or colour’, i.e., to increase the positive force for the negative, and the negative for the positive, to reach a balance.^11,12 From childhood on, the Chinese are educated to control emotions that are considered adverse or disruptive to harmonious social interaction.¹³ When dealing with emotional problems such as depression, Chinese people use coping mechanisms such as quiescence and stoicism and family or cultural support systems, rather than the Western mechanism of seeking help from the social support system.¹⁴

Personality trait differences, relating to the differences between collectivistic and individualistic cultures,^15,16 may also contribute to the uniqueness of bipolar disorders in China. For instance, when referring to the personality traits measured by the Big-Five Model¹⁷ or the Alternative Five-Factor Model,¹⁸ patients with bipolar disorders were found to have higher levels of extraversion, adaptive coping and self-esteem, and lower anxiety versus patients with unipolar depression.¹⁹ Openness to experience in bipolar disorders remains unclear, however, with higher²⁰ and lower²¹ levels of openness being reported compared with unipolar depression or schizophrenia. Regarding the disorder subtypes, higher impulsivity,²² and higher impulsive sensation seeking²³ have been observed in bipolar I compared with bipolar II disorder; and patients with bipolar II disorder have shown higher neuroticism and lower extraversion than patients with bipolar I disorder.²⁴ To the best of the authors’ knowledge, no study has been conducted into whether an emic personality trait in Chinese culture is associated with bipolar disorders. A questionnaire based on the Chinese adjective pool, the Chinese Adjective Descriptors of Personality (CADP), has been developed to measure five dimensions: Intelligent, Emotional, Conscientious, Unsocial and Agreeable; which roughly correspond to the personality domains of the Big-Five Model: Openness to experience, Neuroticism, Conscientiousness, Extraversion and Agreeableness, respectively.²⁵ Interestingly, the factor Intelligent (a trait, which might be highly linked to but not equal to the Intelligence Quotient) became the first (with the highest value) among the explained variances accounted by all personality dimensions, which was different from studies conducted in Western society.^16,17 According to social structural theory,^26,27 higher intelligence might help a Chinese person fit into society. Chinese people dedicate a large amount of attention and financial resources to a child’s education and intelligence assessements,^28,29 and Chinese students sometimes display problems in emotional expression or regulation following an academic failure.³⁰

Among the Big-Five personality traits in affective disorders, besides the prominent traits of extraversion and neuroticism in bipolar disorders,^19,20,24 higher neuroticism has been noted in patients with unipolar depression.^31,32 The authors hypothesized that (I) traits relating to emotional regulation are associated with depression in patients with bipolar II disorder, and (II) traits relating to intelligence are associated with mania in patients with bipolar I disorder. In the current study, Chinese versions of the CADP, the Mood Disorder Questionnaire (MDQ),³³ the Hypomanic Checklist (HCL)-32,³⁴ and the Plutchik–van Praag (PVP) Depression Inventory³⁵ were administered to patients with bipolar I and II disorders and healthy volunteers, with the aim of investigating whether personality traits are related to emotional symptoms (i.e., mania, hypomania, and depression) in Chinese culture.

Patients and methods

Study population

This prospective observational study was conducted at the Department of Psychiatry, Zhejiang Provincial People’s Hospital, and the Department of Clinical Psychology and Psychiatry/School of Public Health, Zhejiang University College of Medicine, Hangzhou, China between March 2011 and May 2013. The study included Chinese Han patients (aged 17–24 years) with bipolar I or bipolar II disorder, who were recruited from the above named institutions, and healthy volunteers who were recruited while attending a clinic for routine examination at the Zijingang Campus of Zhejiang University, Hangzhou, China. Participants who were receiving or had received higher education in administration, computer science, education, economics, preventive medicine, or clinical medicine were sequentially enrolled. Following clinical interviews by two experienced psychiatrists (E.Y. and W.W.), patients were first diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-Text Revision (TR)³⁶ and later confirmed according to the DSM-5.³⁷ Inclusion criteria for patients with bipolar disorder comprised no organic brain lesions, according to magnetic resonance imaging or computed tomography scans, and participants had to be free from antipsychotic drugs or alcohol for ≥72 h prior to testing. Inclusion criteria for healthy volunteers comprised no history of psychiatric or neurological abnormalities, and no alcohol or drug use ≥72 h prior to participating in the study.

The study protocol was approved by the Ethics Committee of Zhejiang University College of Medicine, and all participants provided written informed consent. For participants 17 years of age, written informed consent was obtained from their legal proxies, through a surrogate consent procedure.

Questionnaires

Participants were asked to complete the following four questionnaires in a quiet room under supervision of a member of the current author group.

A. The CADP:²⁵ with 100 Chinese adjectives was designed to measure personality traits such as the Intelligent, Emotional, Conscientious, Unsocial and Agreeable (20 adjectives each). Participants were asked to complete the rating items using the Likert-type scales: 1, very unlike me; 2, moderately unlike me; 3, somewhat like and unlike me; 4, moderately like me; 5, very like me.

B. The MDQ (Chinese version):³³ comprising three parts including 13 forced-choice (yes or no) questions to assess the presence of symptoms and behaviours related to mania or hypomania; one question to determine whether two or more symptoms have been experienced at the same time; one question to determine the extent to which symptoms have caused functional impairment on a scale ranging from ‘no problems’ to ‘serious problems’.

C. The HCL-32 (Chinese version):³⁴ a self-assessment instrument comprising 32 items for detecting hypomanic symptoms. Individuals were instructed to answer the forced-choice (yes or no) questions regarding emotions, thoughts or behaviours, and to answer questions regarding the duration, the impact of family, social and work life, or people’s reactions.

D. The PVP Depression Inventory (Chinese version):³⁵ comprising 34 items, each with a three-point scale (0, 1, 2) corresponding to depressive tendencies. Scores between 20 and 25 were defined as ‘possible depression’ and scores >25 were defined as ‘depression’.

Statistical analyses

Data are presented as mean±SD and participants were divided into three groups: bipolar I disorder, bipolar II disorder and healthy volunteers. Data were analysed using SPSS® software, version 19.0 (SPSS Inc., Chicago, IL, USA). Two-way analysis of variance (ANOVA) was applied to mean scores of the five CADP scales in the three participant groups. One-way ANOVA was applied to the mean MDQ, HCL-32 and PVP scales in three participant groups. Whenever a significant main effect was found, post-hoc analysis using Dunnett’s test was employed to evaluate between-group differences. Pearson’s correlation coefficient was used to search for possible associations between MDQ, HCL-32, PVP and the five CADP scales. In addition, backward stepwise regression was used to confirm the relationships between the five CADP traits, MDQ, HCL-32 and PVP scales, taking CADP traits as potential predictors for the rest scales. All potential predictors were listed according to the publication manual of the American Psychological Association.³⁸ In the current study, a conservative method of calculating the power statistic was chosen, by performing a post-hoc (instead of a priori) analyses and employing the sample size of the smallest group. The power analysis for the two-way ANOVA produced an adequate power statistic of 86.28%. A P value <0.05 was considered to be statistically significant.

Results

A total of 73 patients with bipolar I disorder, 35 patients with bipolar II disorder and 216 healthy participants were enrolled in the current study. Demographic and clinical characteristics of the patients and healthy volunteers are illustrated in Table 1. No statistically significant between-group differences were found in terms of age (one-way ANOVA, F-statistic [2, 321] = 0.99, mean squares error (MSE) = 1.50, P = 0.37), education (F = 0.90, MSE = 1.01, P = 0.41), or sex (χ²= 4.16, P = 0.13).

Table 1.

Demographic and clinical characteristics of Chinese patients with bipolar I and II disorders, and healthy controls.

	Study group
Characteristic	Bipolar I n = 73	Bipolar II n = 35	Healthy control n = 216
Age, years	20.30 ± 1.31 (17 – 24)	20.66 ± 1.06 (18 – 23)	20.42 ± 1.23 (17 – 24)
Sex, female:male	37:36	25:10	124:92
Education level, years	13.42 ± 1.08	13.71 ± .93	13.50 ± 1.07
Obsessive-compulsive disorder	44	22	–
Sleep problem, difficulty falling into/unrefreshing sleep	41	24	–
Suicidal ideation, without attempt	30	18	–
Mania attack	1–4	–	–
Hypomania attack	0–2	1–6	–
Depression attack	3–7	4–10	–
Ongoing mania	12	0	–
Ongoing hypomania	1	2	–
Ongoing depression	30	27	–
Ongoing mixed states, mania/ hypomania, depression	30	6	–
Disease duration, months	29.3 ± 7.4	31.2 ± 8.3	–
Medication (treatment)-naïve	50	17	–
Medicated with anxiolytics, alprazolam, clonazapam or lorazepam	4	5	–
Medicated with antidepressants, fluoxetine or sertraline	15	16	–
Medicated with mood stabilizers, valproate or lithium	9	8	–

Data presented as mean ± SD (range), incidence range or n patients.

Among all participants in the current study, the CADP Likert-type scale internal reliabilities were 0.96 for Intelligent, 0.93 for Emotional, 0.94 for Conscientious, 0.90 for Unsocial and 0.89 for Agreeable, respectively; the MDQ scale internal reliability was 0.82; the HCL-32 scale internal reliability was 0.87; and the PVP scale internal reliability was 0.92.

Mean scores of the five CADP traits were not significantly different between the three groups (group effect, F [2, 321] = 1.59, MSE = 341.04, P = 0.21; Two-way ANOVA; Figure 1). Mean MDQ scores were significantly different between the three groups (F [2, 321] = 479.30, MSE = 1327.60, P < 0.001; one-way ANOVA) and the effect remained after controlling for PVP/HCL-32: patients with bipolar I (P < 0.001; 95% confidence interval [CI] 6.38, 7.46) and bipolar II disorder (P < 0.001; 95% CI 2.18, 3.64) scored significantly higher than healthy controls, and patients with bipolar I scored significantly higher than patients with bipolar II (P < 0.001; 95% CI 3.19, 4.84). Mean HCL-32 scores were significantly different between the three groups (F [2, 321] = 188.79, MSE = 3308.48, P < 0.001) and the effect remained after controlling for PVP/MDQ: patients with bipolar I (P < 0.001; 95% CI 9.20, 11.93) and bipolar II disorder (P < 0.001; 95% CI 4.94, 8.62) scored significantly higher than healthy controls, and patients with bipolar I scored significantly higher than patients with bipolar II (P < 0.001; 95% CI 1.71, 5.86). Mean PVP scores were also significantly different between the three groups (F [2, 321] = 118.77, MSE = 6624.30, P < 0.001) and the effect remained after controlling for MDQ/HCL-32: patients with bipolar II scored significantly higher than patients with bipolar I disorder (P < 0.001; 95% CI 8.75, 16.14) and healthy controls (P < 0.001; 95% CI 16.68, 23.23), and patients with bipolar I scored significantly higher than healthy controls (P < 0.001; 95% CI 5.07, 9.94; Figure 2).

Figure 1.

Chinese adjective descriptors of personality scores in healthy controls (n = 216) and Chinese patients with bipolar I (BD I, n = 73) and II (BD II, n = 35) disorders. Data presented as mean ± SD. There were no statistically significant between-group differences.

Figure 2.

Mood Disorder Questionnaire (MDQ), Hypomania Checklist-32 (HCL-32), and Plutchik-van Praag Depression Inventory (PVP) scores in healthy controls (n = 216) and Chinese patients with bipolar I (BD I, n = 73) and II (BD II, n = 35) disorders. Data presented as mean ± SD. *P < 0.05 versus controls; **P < 0.05 versus BD I.

Several statistically significant correlations were detected between MDQ, HCL-32, and PVP scales and personality traits within the three study groups (Pearson’s correlation coefficient; Table 2). In patients with bipolar I disorder, MDQ was significantly correlated with Intelligent (n = 73, r = 0.25), and PVP was significantly correlated with Emotional (r = 0.33). In patients with bipolar II disorder, although the relationships between MDQ and Intelligent (n = 35, r = 0.20), Unsocial (r = 0.27) and Agreeable (r = −0.22), and between HCL-32 and Intelligent (r = −0.27), Emotional (r = −0.26), Conscientious (r = −0.23) and Agreeable (r = −0.26) were at lower to medium levels, they were not statistically significant. By contrast, PVP was significantly correlated with Intelligent (n = 216, r = −0.22) and Emotional (r = 0.21) in healthy controls.

Table 2.

Correlation between the Mood Disorder Questionnaire, Hypomania Checklist-32, and Plutchik-van Praag Depression Inventory, and the Chinese Adjective Descriptors of Personality in Chinese patients with bipolar I (n = 73) and II (n = 35) disorders and healthy controls (n = 216).

		Chinese Adjective Descriptors of Personality
Questionnaire	Study group	Intelligent	Emotional	Conscientious	Unsocial	Agreeable
The Mood Disorder Questionnaire	Control
	Bipolar I	0.25*
	Bipolar II	0.20			0.27	−0.22
The Hypomania Checklist-32	Control
	Bipolar I
	Bipolar II	−0.27	−0.26	−0.23		−0.26
The Plutchik-van Praag Depression Inventory	Control	−0.22**	0.21**
	Bipolar I		0.33**
	Bipolar II

For clarity, only r| ≥ 0.20 are shown; *P < 0.05; **P < 0.01 (Pearson’s correlation coefficient).

Some relationships between the MDQ, HCL-32 and PVP scales and personality traits were replicated using backward stepwise regression analysis, although the adjusted R² values were relatively small (Table 3). In patients with bipolar I disorder (n = 73), the CADP Intelligent trait (β = 0.25) predicted the MDQ; the Intelligent (β = −0.24), Agreeable (β = 0.26), and Emotional (β = 0.34) traits predicted the PVP. In patients with bipolar II disorder (n = 35), the Intelligent (β = 0.22), Agreeable (β = −0.24), and Unsocial (β = 0.31) traits predicted the MDQ; and the Intelligent (β = −0.20), Agreeable (β = −0.31), and Emotional (β = −0.26) traits predicted the HCL-32.

Table 3.

Backward stepwise regression results for predicting the Mood Disorder Questionnaire, Hypomania Checklist-32, and Plutchik–van Praag Depression Inventory using the Chinese Adjective Descriptors of Personality in Chinese patients with bipolar I and II disorders and healthy controls.

		Control group n = 216		Bipolar I group n = 73		Bipolar II group n = 35
Questionnaire	aR²	β, predictor	aR²	β, predictor	aR²	β, predictor
The Mood Disorder Questionnaire			0.05	0.25 Intelligent	0.10	0.22 Intelligent −0.24 Agreeable 0.31 Unsocial
The Hypomania Checklist-32			0.01	−0.15 Emotional	0.13	−0.20 Intelligent −0.31 Agreeable −0.26 Emotional
The Plutchik–van Praag Depression Inventory	0.08	−0.16 Intelligent −0.10 Agreeable 0.17 Emotional	0.15	−0.24 Intelligent 0.26 Agreeable 0.34 Emotional

For clarity, β ≥ 0.20 are in bold; aR², adjusted R².

Discussion

In the current study and consistent with previous reports,^39,40 patients with bipolar I and II disorder scored higher than healthy controls on MDQ, HCL-32 and PVP questionnaires. Also consistent with previous reports,^41,42 patients with bipolar I disorder scored higher on the MDQ than those with bipolar II disorder, and patients with bipolar II disorder scored higher on the HCL-32 and PVP than those with bipolar I. Using backward stepwise regression analyses, relationships between personality traits and emotional scales were found in patients with bipolar disorders rather than in healthy controls. The associations found in patients in the current study confirmed, in part, the hypothesis that traits relating to intelligence are associated with mania in patients with bipolar I disorder, and partly concurred with the findings of the Big-Five personality traits in affective disorders.^{19,20,24,31,32}

In the current study, the CADP Intelligent trait was significantly correlated with the MDQ in patients with bipolar I disorder, which confirmed the hypothesis that traits relating to intelligence are associated with mania, and concurred with the idea that high intelligence has a greater link to mood disorders.⁴³ There might also be a Chinese cultural contribution to the relationship between intelligence and bipolar disorders. For instance, the Chinese ancient philosophical conceptions of intelligence differ markedly from those of ancient and contemporary Western traditions.⁴⁴ The Chinese people generally interpret the term intelligence as a higher mental process:⁴⁵ From the Confucian perspective, the image of an intelligent person is one who devotes his life to personality cultivation so that he will be able to embody benevolence and act according to what is right; from a Taoist perspective, an intelligent person is one who knows the Tao, i.e., the true greatness, and can put this understanding into practice.⁴⁴ Thus, it may be understandable that the Chinese respect intelligence to a great extent and are very proud of being intelligent, and this might be particularly the case in patients suffering from mania.

In patients with bipolar I disorder, the CADP Intelligent trait was negatively correlated with the PVP in the current study. Intelligent people may be more inclined to develop increased cognitive awareness where more complex or multiple factors are involved in social success.⁴⁶ Moreover, individuals who are better educated and more intelligent have been shown to have a lower risk of depression.⁴⁷ In the current study and consistent with previous results,^48,49 the Agreeable trait was also found to be positively correlated with the PVP. From the Chinese cultural aspect, obedience, quietness and patience are frequently emphasized in primary schools,⁵⁰ and studies of Chinese organizational behaviour also reveal that employees are selected mostly on the basis of their obedience to current employers.⁵¹ An accumulation of excessive or over-expressed agreeableness, however, has been shown to lead to depression.^52,53 Moreover, the current study showed that the Emotional trait significantly predicted the PVP and, contrary to the authors hypothesis that emotional regulation is associated with depression in patients with bipolar II disorder, this correlation was not found in patients with bipolar II but was found in patients with bipolar I disorder. There is an established explanation for the relationship between the Emotional trait and depression, i.e., the Emotional trait resembles neuroticism,²⁵ and the latter is highly connected with depression.⁵⁴

In the current study, the CADP Intelligent trait was correlated with the MDQ in patients with bipolar II as well as bipolar I disorder, which extended beyond the authors’ hypothesis that traits relating to intelligence are associated with mania in patients with bipolar I disorder. In addition, the Agreeable trait was negatively correlated with the MDQ, in line with the previously reported negative association between agreeableness and manic severity in bipolar disorders.^24,55,56 The Unsocial trait was also found to be positively correlated with the MDQ in the current study, in line with the following findings: the Unsocial trait represents a negative pole of Extraversion,²⁵ and the latter was decreased in bipolar II patients.²⁴

In the current study, the negative correlation found between the Intelligent trait and HCL-32 in patients with bipolar II disorder contradicted the positive correlation between the Intelligent trait and MDQ found in both of the bipolar groups. In support of this negative correlation, it is thought that high intelligence and hypomania together may result in antisocial behaviour,⁵⁷ and patients with bipolar disorder may often utilize their intelligence by adopting depressive inhibition to suppress their behavioural activation system instead,⁵⁸ which might result in a less prominent hypomanic state. Moreover, the Agreeable trait showed a negative relationship with the HCL-32 scale, which was similar to the negative relationship between the Agreeable trait and the MDQ found in the current study, and supports the finding that patients with bipolar II disorder display less agreeableness or lower treatment-compliance in clinics.⁵⁹ A negative correlation was found between the Emotional trait and HCL-32 in the current study. Contrary to the authors’ first hypothesis, the Emotional trait was not positively correlated with the PVP in patients with bipolar II disorder, but was negatively correlated with HCL-32 in this pathology. Whether this association was related to Chinese culture remains unknown. Nevertheless, results from studies conducted in Oriental countries support this finding. For instance, in a Japanese study,⁶⁰ patients with bipolar II and a panic disorder comorbidity presented lower neuroticism than patients with bipolar I and panic disorder comorbidity. In a Korean study,²⁴ patients with bipolar II disorder scored lower on positive emotion than those with bipolar I.

Limitations in the present study design should also be considered. First, the participants were well-educated young people aged 17–24 years, and the results may not, therefore, be generalizable to other age populations. Secondly, the Minnesota Multiphasic Personality Inventory⁶¹ and the Eysenck Personality Questionnaire⁶² were not employed to measure personality, nor was personality disorder comorbidity noted in the participants. Thus, whether these traits are related to emotional symptoms in patients with bipolar disorder or to the affective states of healthy people remains unanswered. Thirdly, the present study was only conducted in China without a control group of Western participants. Fourthly, the sample sizes were small, which produced weak prediction powers (lower adjusted R² values) of personality traits to emotional symptoms, therefore, the associations between the two should be further investigated with a large sample design.

In conclusion, the present results support other studies which show that Chinese people emphasize Intelligent and Agreeable traits,^44,45 and also suggest that the four traits (Intelligent, Emotional, Unsocial and Agreeable) contribute to emotional symptoms differently in patients with bipolar I and II disorders. The present study, from a limited aspect, might offer culture-related clues to study emotional expression or control in Chinese people, to study the trait-bases of the two types of bipolar disorder, and to develop bipolar type-specific psychotherapy strategies.

Footnotes

Declaration of conflicting interest

The authors declare that there are no conflicts of interest.

Funding

The study was supported by a grant from the National Natural Science Foundation of China (No. 91132715) to Dr. W. Wang, and by a Key Program from the Department of Science and Technology, Zhejiang Province (2013T01) to Dr. E. Yu.

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Relationship between Chinese adjective descriptors of personality and emotional symptoms in young Chinese patients with bipolar disorders

Abstract

Objective

Methods

Results

Conclusions

Keywords

Introduction

Patients and methods

Study population

Questionnaires

Statistical analyses

Results

Discussion

Footnotes

Declaration of conflicting interest

Funding

References