Temperament and Character Dimensions of Personality in Patients with Generalized Anxiety Disorder

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10 Journal of Mood Disorders Volume: 7, Number: 1, 2017 - www.jmood.org
Original Paper DOI: 10.5455/jmood.20170214015231
Temperament and Character Dimensions of
Personality in Patients with Generalized Anxiety
Disorder
Zeynep Ezgi Bal, MD1, Mustafa Solmaz, MD1, Derya Adali Aker, MD1, Ercan Akin, MSc2,
Samet Kose, MD, PhD2,3
1Bagcilar Research and Training Hospital ,
Department of Psychiatry, Istanbul, Turkey,
2Hasan Kalyoncu University, Department of
Psychology, Gaziantep, Turkey
3University of Texas Medical School of
Houston, TX, USA and Center for
Neurobehavioral Research on Addictions,
Houston, TX, USA.
Corresponding Author:
Samet Kose, MD, PhD,
Franklin, TN, USA
E-ma il add ress:
sametkose@gmail.com
Date of received:
February 1, 2017
Da te of ac cep tan ce:
February 14, 2017
Declaration of interest:
Z.E.B., M.S., D.A.A., E.A., S.K.: The authors
reported no conflicts of interest related to this
article.
ABS TRACT:
Temperament and character dimensions of personality in patients with generalized anxiety
disorder
Objective: It is known that a complex relationship is present between anxiety and personality. In this study, we aimed
to compare the clinical features and personality traits of patients with GAD and healthy controls. We hypothesized that
Harm Avoidance scores would be higher and predictive of GAD compared to the healthy controls.
Methods: This study was conducted in outpatients with GAD who presented to the Bagcilar Training and Research
Hospital’s Outpatient Psychiatry Clinic. The sample was comprised of 40 outpatient (30 women, 10 men) who met
Diagnostic and Statistical Manual of Mental Disorders - DSM-5 criteria for GAD, who were not under any medication
treatments. The control group comprised of 40 healthy controls (23 women, 17 men). Semi-structured sociodemographic
data form, Temperament and Character Inventory (TCI), General Anxiety Disorder Scale (GAD-7), Beck Depression
Inventory (BDI), the Beck Anxiety Inventory (BAI), State-Trait Anxiety Inventory (STAI-I and II) were administered to the
participants. All statistical analyses were performed using SPSS for Windows, Version 23.0.
Results: Impulsiveness subscale of Novelty Seeking; Harm Avoidance and its subscales of Anticipatory worry, Fear
of uncertainty, Shyness with strangers, and Fatigability and asthenia scores were significantly higher in GAD patients
compared to the control group. Harm Avoidance and its subscales of Anticipatory worry, Fear of uncertainty, Shyness
with strangers, and Fatigability and asthenia scores were significantly highly positively correlated with the BDI, BAI,
STAI-I / STAI-II, and GAD-7 scores. When GAD-7 scores was entered as the dependent variable and age and gender were
controlled in regression analysis, Harm Avoidance and its subscale of Shyness, Persistence, and Self-Transcendence were
significantly predictive of GAD-7 scores.
Conclusions: Temperament and character traits of the GAD patients were significantly different from the healthy control
subjects. HA scores were higher and predictive of GAD compared to healthy controls.
Keywords: General Anxiety Disorder, temperament and character inventory, personality, harm avoidance
Journal of Mood Disorders (JMOOD) 2017;7(1):10-9
INTRODUCTION
Generalized Anxiety Disorder (GAD) is a highly distressing
disorder characterized by chronic and excessive worry
surrounding various aspects of an individual’s life. Although
there are a number of findings suggesting that certain
genetic, biological, psychological, and psychosocial factors
may be involved in the development of GAD (1) suggesting
multicausality, understanding the etiology of GAD is still
extremely limited. However, it is known that a complex
relationship is present between anxiety and personality (2,3).
In Cloninger’s psychobiological model of temperament
and character, relationships between the structure and
development of personality and psychiatric disorders are
described (4). This model postulates that personality is
comprehensively developed with respect to genetic traits,
learning, and insight into the self-concept. Cloninger’s
model consists of four temperament and three character
dimensions, all of which are viewed as being the results of
continuous interactions during the lifespan (5).
Temperament is largely genetically determined,
independently manifested in early life, and configures

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Journal of Mood Disorders Volume: 7, Number: 1, 2017 - www.jmood.org
Bal ZE, Solmaz M, Adali-Aker D, Akin E, Kose S
automatic behavior responses. Four dimensions of
temperament are Novelty Seeking (NS), Harm Avoidance
(HA), Reward Dependence (RD), and Persistence (P).
Novelty Seeking (NS) refers to a heritable bias in the
activation and initiation of behavior and higher levels of
NS are linked with curiosity, enthusiasm, and engagement
with something new and unfamiliar, but also with
impulsivity, anger, and disengagement when felt frustrated
(6). Harm Avoidance (HA) indicates a heritable bias for
inhibition and cessation of behaviors and higher levels of
HA are linked to caution, care and good planning skills, but
also with avoidance, passivity, insecurity, wariness,
pessimism, and low energy (6). Reward Dependence (RD)
refers to a heritable bias for maintenance of ongoing
behavior and higher levels of RD are linked to sensibility,
sociability, and empathy (6). Persistence (P) refers to the
perseverance and eagerness of effort in response to signals
of anticipated reward vs. laziness, ambitious overachieving
in response to intermittent frustrating non-reward vs.
underachieving and higher levels of P are linked to stability,
industriousness, sense of duty, and perfectionism (6).
Character involves individual differences in higher
cognitive processes. Character regulates the cognitive
processes of sensory perception and emotion provoked by
temperament, leading to the development of a mature
concept of the self in the personal, social, and spiritual
arenas. These traits are mostly determined by the
environment rather than being inherited. Self-
Directedness (SD) refers to identification with the
autonomous self and the ability of an individual to control,
regulate, and adapt his or her behavior to t the situation
in accordance with one’s individually chosen goals and
values to deal with any situations encountered and higher
levels of SD are linked to maturity, efficiency, self-
sufciency, responsibility, and high self-esteem and self-
reliance (6). Cooperativeness (C) indicates the extent to
which individuals view other people as a part of the self
and higher levels of C are linked to tolerance, sympathy,
sociability, and empathy (6). Self-Transcendence (ST)
refers to identication with a unity of all things in the world
and higher levels of ST are linked to patience, selessness,
spirituality, idealism, and creativity (6).
In terms of his personality model, Cloninger proposed
that anxiety disorders were correlated with higher HA,
lower NS and RD scores (7). He described three forms of
anxiety. First one is ‘chronic somatic anxiety’ which is
related to higher NS, lower HA and RD as in panic disorder,
the second one is ‘chronic cognitive anxiety’ related to
higher HA, lower NS and RD as in Generalized Anxiety
Disorder. The last form is ‘mixed somatic and cognitive
anxiety’ which is proposed to be related to higher HA and
NS (7) . Generalized anxiety disorder patients, with their
heightened anticipatory anxiety and feeling afraid as if
something awful might happen, clinically t the denition
of ‘chronic cognitive anxiety’ (7). Both HA and GAD refer
shared features of feeling habitually tense and worried. The
relationship between anxiety disorders and personality
traits, with respect to temperament and character
dimensions, has been the subject of numerous studies
using the dimensional approach to the psychobiological
model of personality. Previous studies, comparing
temperament and character dimensions of GAD patients
and healthy controls, revealed controversial results. It
seems that the only consistent finding is that report of
higher HA scores (8-11). Starcevic et al. reported higher HA
and lower RD scores in GAD patients and no differences
between the NS scores (11). Piero et al. reported higher HA
and NS scores and lower RD and SD scores in GAD patients
(9). There were also previous reports of lower SD scores in
GAD patients (12,13).
In this study, we aimed to examine the clinical features
and personality traits of patients with General Anxiety
Disorder compared to healthy controls. Our study
hypothesis was that the temperament and character traits
of the patients would be different from the healthy group.
We hypothesized that HA scores would be higher and
predictive of GAD compared to healthy controls. In other
words, we predict that it would be more common for an
individual to express higher levels of harm avoidance in the
presence of GAD relative to the healthy controls.
MATERIAL AND METHODS
Study Participants
This study was conducted in outpatients with generalized
anxiety disorder who were admitted to the Psychiatric Unit
of Bagcilar Training and Research Hospital. The sample
was comprised of 40 outpatient (30 women, 10 men) with a
mean age of 38.25 years (SD±8.2 years) who met Diagnostic
and Statistical Manual of Mental Disorders - DSM-5 criteria
(14) for General Anxiety Disorder (GAD), who were not

12 Journal of Mood Disorders Volume: 7, Number: 1, 2017 - www.jmood.org
Temperament and character dimensions of personality in patients with generalized anxiety disorder
under any medication treatments. The control group
comprised of 40 healthy controls (23 women, 17 men), with
a mean age of 36.2 years (SD±11.17) years. Both study
groups had no history of any psychotic disorders and were
free of any medical illnesses and neurological disease. The
current study was approved by the Ethics Committee of our
hospital, and all of the patients gave written informed
consent before participation.
Psychometric Measurements
Sociodemographic Data Form.
This form includes
demographic variables including gender, age, marital
status, the number of children, education, location,
household members, occupation, employment status, the
number of siblings, family history of chronic disease, other
known physical illnesses, and previous psychiatric
treatments.
General Anxiety Disorder Inventory (GAD-7).
General
Anxiety Disorder severity was evaluated with a self-report
scale, specifically the 7-item General Anxiety Disorder
Inventory (GAD-7) (15), the 21-item Beck Anxiety Inventory
(BAI) (16) and the State-Trait Anxiety Inventory (STAI-I and
II) (17).
Turkish TCI. Temperament and Character Inventory
(TCI) is a self-administered, 240-item true/false
questionnaire. The depressed patients completed a Turkish
version of the 240-item self-questionnaire (Turkish-TCI) at
the end of the psychiatric interview, and the control group
received the instruction to complete the questionnaire at
home. All participants gave informed consent. The TCI is a
240-item self-administered questionnaire that measures
the four temperament dimensions and the three character
dimensions (4). The Turkish-TCI has been validated by
Kose et al., in a Turkish sample of 683 healthy volunteers
(18). All diagnostic assessments and clinical ratings were
performed by two staff psychiatrists.
General Anxiety Disorder Inventory (GAD-7).
The 7-item
Generalized Anxiety Disorder Scale (GAD-7) was developed
by Spitzer et al. based on the GAD criteria found in the
DSM-5. The GAD-7 score is calculated by assigning scores
of 0, 1, 2, and 3, to the response categories of ‘not at all’,
‘several days’, ‘more than half the days’, and ‘nearly every
day’, respectively, and adding together the scores for the
seven questions. Scores of 5, 10, and 15 are taken as the cut-
off points for mild, moderate and severe anxiety,
respectively (15). Further evaluation is recommended when
the score is 10 or greater. Using the threshold score of 10,
the GAD-7 has a sensitivity of 89% and a specicity of 82%
for GAD. The Turkish GAD-7 has been validated by Konkan
et al. (19).
Beck Depression Inventory (BDI).
Beck Depression
Inventory (BDI) is a self-report scale composed of 21 items
and measures somatic, emotional, cognitive, and impulsive
symptoms of depression. Each item takes a point between 0
and 3. The point that can be taken from inventory varies
between 0 and 63 and high points indicate a rise in the
depressive mood. The scale aims not to diagnosis but
converts the symptoms level to the objective number (20).
Overall scores for all questions is evaluated as followed: a
score between 10-16 shows low depression symptom, a
score between 17-29 is middle depressive symptom, and a
score between 30-63 is severe depressive symptom. BDI has
been adapted into Turkish, and the reliability and validity
have been examined by Hisli (21).
Beck Anxiety Inventory (BAI).
The BAI is a 21-item self-
report questionnaire that lists the symptoms of anxiety. The
respondent is asked to rate how much each symptom has
bothered him/her in the past week. The symptoms are
rated on a four-point scale, ranging from ‘‘not at all’’ (0) to
‘‘severely’’ (3). The instrument has excellent internal
consistency of Chronbach’s alpha=0.92) and high test–
retest reliability (r=0.75) (22).
State-Trait Anxiety Inventory.
State-Trait Anxiety
Inventory was developed by Spielberger et al. in 1970, and it
is a Likert-type scale that measures the level of state and
trait anxiety with 20 questions for each. While State Anxiety
Inventory evaluates the sensational reaction that shows
sudden changes Trait Anxiety Inventory at the second part
of the inventory measures the continuity of the anxiety that
people generally show tendency throughout life. Higher
scores show higher anxiety level, and lower scores show
lower anxiety level. The items are ranked between 1 (never)
and 2 (completely). The total score obtained from both
inventories changes between 20 and 80. Inventory has been
introduced to Turkish with reliability and validity study
conducted by Oner and Le Compte (17).

13
Journal of Mood Disorders Volume: 7, Number: 1, 2017 - www.jmood.org
Bal ZE, Solmaz M, Adali-Aker D, Akin E, Kose S
Statistical Analysis
All statistical analyses were performed using SPSS for
Windows, Version 23.0. The variables in the present study
were examined with the Kolmogorov-Smirnov’s test of
normality. All variables were normally distributed. An
independent sample t-test was used for comparisons
between the patient and the control groups. Within-group
correlations between TCI scores were performed using the
Pearson’s correlation coefficient. Hierarchical Multiple
Regression analysis was performed to examine the
association between the Generalized Anxiety Disorder
Scale (GAD-7) scores and TCI’s temperament and character
dimensions. A p value less than 0.05 was considered
statistically signicant.
RESULTS
Sociodemographic Characteristics of Sample
The mean age of the study participants was 37.23±9.786
years (X±SD); 33.8% (n=27) of participants were male;
66.3% (n=53) were female. The majority of the participants
in the study were married (76.3%) and 15% of participants
were single, 3.8% were divorced, 1.3% were widowed. 31
participants (38.8%) were graduated from elementary
school, 20 (25.0%) from high school, 20 (25.0%) from
college, and 8 (10.0%) participants were graduated from
middle school. The majority of participants in the study
were housekeeper (31.3%), and 22.5% of participants were
workers. Other participants were government employees
(n=9), retired (n=4), student (n=2), freelancer (n=6), and 9
participants (11.3%) in the study were unemployed. Among
the participants in the study, 24 (30.0%) had psychiatric
family history [generalized anxiety disorder (n=3), panic
disorder (n=4), major depressive disorder (n=15), bipolar
disorder (n=1), and schizophrenia (n=1)]. A half of
participants were smoking cigarettes (50%) and the other
half were not (%50). 32% of participants were alcohol users,
and %32.5 of the participants had alcohol use history in the
past. 13.8% of participants attempted suicide.
Sociodemographic characteristics of participants were
presented in Table 1.
Comparing TCI scales and subscales between GAD
patients and healthy controls
An independent-samples t-test was conducted to compare
TCI scales and subscales scores for patient and control
groups. The results revealed that there was a statistically
signicant difference between the patients and controls in
terms of Impulsiveness subscale scores of Novelty Seeking
(t(78)=3.698, p=0.000); Harm Avoidance (t(78)=15.962,
p=0.000) and its subscales of Anticipatory worry
(t(78)=11.840, p=0.000), Fear of uncertainty (t(78)=8.441,
p=0.000), Shyness with strangers (t(78)=12.410, p=0.000),
and Fatigability and asthenia (t(78)=10.996, p=0.000),
Exploratory Excitability (t(78)=-3.989, p=0.000); Reward
Dependence (t(78)=-2.359, p=0.21) and its subscale of
Table 1: Sociodemographic characteristics of the sample
n %
Gender
Female 53 66.3
Male 27 33.8
Marital status
Married 61 76.3
Single 15 18.8
Divorced 3 3.8
Widowed 1 1.3
Education
Elementary School 31 38.8
Middle School 8 10.0
High School 20 25.0
College 20 25.0
Other 1 1.3
Profession
Unemployed 9 11.3
Worker 18 22.5
Government Employee 9 11.3
Housekeeper 25 31.3
Other 19 23.6
Psychiatric Family History
Present 24 30.0
Absent 56 70.0
Psychiatric Illness in Family
None 56 70.0
GAD 3 3.8
Panic Disorder 4 5.0
MDD 15 18.8
Bipolar Disorder 1 1.3
Schizophrenia 1 1.3
Nicotine Use
Present 40 50.0
Absent 40 50.0
Past Alcohol Substance Use
Neither 54 67.5
Alcohol 26 32.5
Suicide Attempt
Present 11 13.8
Absent 69 86.3

14 Journal of Mood Disorders Volume: 7, Number: 1, 2017 - www.jmood.org
Temperament and character dimensions of personality in patients with generalized anxiety disorder
Attachment (t(78)=-4.479, p=0.000); Persistence (t(78)=-4.071,
p=0.000); Self-Directedness (t(78)=-8.302, p=0.000) and its
subscales of Responsibility (t(78)=-6.043, p=0.000),
Purposefulness (t(78)=-4.759, p=0.000), Resourcefulness
(t(78)=-8.892, p=0.000), and Congruent Second Nature
(t(78)=-6.028, p=0.000); Social Acceptance subscale of
Cooperativeness (t(78)=-4.245, p=0.000). Impulsiveness
subscale of Novelty Seeking (
X
patient=4.45, SDPatient=1.947;
X
Control=3.00, SDControl=1.536); Harm Avoidance (
X
patient=28.30, SDPatient=3.681;
X
Control=12.40, SDControl=5.113)
and its subscales of Anticipatory worry (
X
patient=8.85,
SDPatient=1.861;
X
Control=3.85, SDControl=1.916), Fear of
uncertainty (
X
patient=6.20, SDPatient=0.966;
X
Control=3.60,
SDControl=1.692), Shyness with strangers (
X
patient=6.25,
SDPatient=1.354;
X
Control=1.88, SDControl=1.771), and
Fatigability and asthenia (
X
patient =7.00, SDPatient=1.485;
X
Control=3.08, SDControl=1.700) scores were signicantly higher
in GAD patients compared to the controls. On the other
hand, Exploratory Excitability (
X
patient=4.15, SDPatient=1.718;
X
Control=5.70, SDControl=1.757); Reward Dependence (
X
patient=7.00, SDPatient=1.485;
X
Control=3.08, SDControl=1.700)
and its subscale of Attachment (
X
patient=3.65, SDPatient=1.718;
X
Control=5.18, SDControl=1.299); Persistence (
X
patient=4.25,
SDPatient=1.850;
X
Control=5.70, SDControl=1.285); Self-
Directedness (
X
patient=21.85, SDPatient=6.302;
X
Control=31.73,
SDControl=4.107) and its subscales of Responsibility (
X
patient=3.43, SDPatient=2.147;
X
Control=6.03, SDControl=1.672),
Purposefulness (
X
patient=4.50, SDPatient=1.854;
X
Control=6.23,
SDControl=1.349), Resourcefulness (
X
patient=1.83,
SDPatient=1.318;
X
Control=4.05, SDControl=0.876), and
Congruent Second Nature (
X
patient=6.70, SDPatient=2.174;
X
Control=9.35, SDControl=1.733); Social Acceptance subscale of
Cooperativeness (
X
patient=5.38, SDPatient=1.659;
X
Control=6.80, SDControl=1.324) scores were signicantly lower
Table 2: Comparing TCI Scales and Subscales between Patients and Healthy Controls
Group n XSD t df p
NOVELTY SEEKING
Impulsiveness Patient 40 4.45 1.947 3.698 78 0.000
Healthy 40 3.00 1.536
Exploratory Excitability Patient 40 4.15 1.718 -3.989 78 0.000
Healthy 40 5.70 1.757
HARM AVOIDANCE Patient 40 28.30 3.681 15.962 78 0.000
Healthy 40 12.40 5.113
Anticipatory Worry Patient 40 8.85 1.861 11.840 78 0.000
Healthy 40 3.85 1.916
Fear of Uncertainty Patient 40 6.20 0.966 8.441 78 0.000
Healthy 40 3.60 1.692
Shyness Patient 40 6.25 1.354 12.410 78 0.000
Healthy 40 1.88 1.771
Fatigability Patient 40 7.00 1.485 10.996 78 0.000
Healthy 40 3.08 1.700
REWARD DEPENDENCE Patient 40 14.05 2.961 -2.359 78 0.021
Healthy 40 15.63 3.010
Attachment Patient 40 3.65 1.718 -4.479 78 0.000
Healthy 40 5.18 1.299
PERSISTANCE Patient 40 4.25 1.850 -4.071 78 0.000
Healthy 40 5.70 1.285
SELF-DIRECTEDNESS Patient 40 21.85 6.302 -8.302 78 0.000
Healthy 40 31.73 4.107
Responsibility Patient 40 3.43 2.147 -6.043 78 0.000
Healthy 40 6.03 1.672
Purposefulness Patient 40 4.50 1.854 -4.759 78 0.000
Healthy 40 6.23 1.349
Resourcefulness Patient 40 1.83 1.318 -8.892 78 0.000
Healthy 40 4.05 0.876
Congruent Second Nature Patient 40 6.70 2.174 -6.028 78 0.000
Healthy 40 9.35 1.733
COOPERATIVENESS
Social Acceptance Patient 40 5.38 1.659 -4.245 78 0.000
Healthy 40 6.80 1.324

15
Journal of Mood Disorders Volume: 7, Number: 1, 2017 - www.jmood.org
Bal ZE, Solmaz M, Adali-Aker D, Akin E, Kose S
in GAD patients compared to the controls. The results of
TCI scales and subscales differences between GAD patients
and controls are presented in Table 2.
Correlation of TCI scales and Subscales with Other
Scales Scores
There were statistically significant and strong positive
correlations between Harm Avoidance scale and its
subscales with BDI, BAI, GAD-7, and State Anxiety and Trait
Anxiety scores. Harm Avoidance was statistically
signicantly and positively correlated with BDI (r=0.808,
p<0.01), BAI (r=0.851, p<0.01), GAD-7 (r=0.861, p<0.01),
State Anxiety (r=0.843, p<0.01) and Trait Anxiety (r=0.879,
p<0.01) scores. Anticipatory worry was positively and
statistically significantly correlated with BDI (r=0.807,
p<0.01), BAI (r=0.800, p<0.01), GAD-7 (r=0.791, p<0.01), and
State Anxiety (r=0.831, p<0.01) and Trait Anxiety (r=0.713,
p<0.01). Fear of uncertainty subscale of Harm Avoidance
was positively and statistically signicantly correlated with
BDI (r=0.606, p<0.01), BAI (r=0.669, p<0.01), GAD-7
(r=0.719, p<0.01), State Anxiety (r=0.688, p<0.01) and Trait
Anxiety (r=0.713, p<0.01). Shyness with strangers subscale
of Harm Avoidance was positively and statistically
significantly correlated with BDI (r=0.722, p<0.01), BAI
(r=0.752, p<0.01), GAD-7 (r=0.783, p<0.01), State Anxiety
(r=0.789, p<0.01) and Trait Anxiety (r=0.776, p<0.01).
Similarly, Fatigability and asthenia scores subscale was
positively and statistically signicantly correlated with BDI
(r=0.694, p<0.01), BAI (r=0.779, p<0.01), GAD-7 (r=0.756,
p<0.01), and State Anxiety (r=0.713, p<0.01) and Trait
Anxiety (r=0.781, p<0.01).
On the other hand, there were statistically signicant
and strong negative correlations between Self-Directedness
scale (including all of its subscales except for Self-
acceptance) and the BDI, BAI, STAI-I / STAI-II, and GAD-7
scores. Self-Directedness scale was statistically signicantly
and negatively correlated with BDI (r=-0.665, p<0.01), BAI
(r=-0.726, p<0.01), GAD-7 (r=-0.668, p<0.01), State Anxiety
(r=-0.641, p<0.01) and Trait Anxiety (r=-0.689, p<0.01).
Responsibility subscale was statistically significantly and
negatively correlated with BDI (r=-0.620, p<0.01), BAI
(r=-0.653, p<0.01), GAD-7 (r=-0.597, p<0.01), State Anxiety
(r=-0.593, p<0.01) and Trait Anxiety (r=-0.608, p<0.01).
Purposefulness subscale of Self-Directedness was
statistically signicantly and negatively correlated with BDI
(r=-0.511, p<0.01), BAI (r=-0.520, p<0.01), GAD-7 (r=-0.475,
p<0.01), State Anxiety (r=-0.418, p<0.01) and Trait Anxiety
(r=-0.537, p<0.01). Resourcefulness subscale was
statistically signicantly and negatively correlated with BDI
(r=-0.669, p<0.01), BAI (r=-0.712, p<0.01) , GAD-7 (r=-0.689,
p<0.01), State Anxiety (r=-0.728, p<0.01) and Trait Anxiety
(r=-0.692, p<0.01). Congruent Second Nature subscale of
Self-Directedness was statistically significantly and
negatively correlated with BDI (r=-0.669, p<0.01), BAI
(r=-0.712, p<0.01), GAD-7 (r=-0.689, p<0.01), State Anxiety
(r=-0.728, p<0.01) and Trait Anxiety (r=-0.692, p<0.01). The
results of Pearson’s correlation between TCI scales and
subscales and BDI, BAI, GAD-7, STAI-I / STAI-II scores are
presented in Table 3.
The Predictors of GAD-7 Scores
The hypothesized relationship between GAD-7 scores and
TCI scales were tested in two separate hierarchical multiple
regression. The demographic variables (age, gender) were
entered in the first step of the hierarchical multiple
regression. TCI scales were entered in the second steps of
Table 3: Correlations between TCI and Other Scale Scores
BDI BAI GAD-7 STAI-I STAI-II
HARM AVOIDANCE 0.808** 0.851** 0.861** 0.843** 0.879**
Anticipatory Worry 0.807** 0.800** 0.791** 0.785** 0.831**
Fear of Uncertainty 0.606** 0.669** 0.719** 0.688** 0.713**
Shyness 0.722** 0.752** 0.783** 0.789** 0.776**
Fatigability 0.694** 0.779** 0.756** 0.713** 0.781**
SELF-DIRECTEDNESS -0.665** -0.726** -0.668** -0.641** -0.689**
Responsibility -0.620** -0.653** -0.597** -0.593** -0.608**
Purposefulness -0.511** -0.520** -0.475** -0.418** -0.537**
Resourcefulness -0.669** -0.712** -0.689** -0.728** -0.692**
Congruent Second Nature -0.588** -0.532** -0.506** -0.445** -0.494**
**Correlation is significant at the 0.01 level (2-tailed).

16 Journal of Mood Disorders Volume: 7, Number: 1, 2017 - www.jmood.org
Temperament and character dimensions of personality in patients with generalized anxiety disorder
the hierarchical regression analyses. The results indicated
that Harm Avoidance, Persistence, and Self-Transcendence
were signicantly predictive of GAD-7 scores (R2=0.796, F
(2,77)=30.292, p=0.000). The results of the hierarchical
multiple regression analysis are presented in Table 4.
Moreover, the relationship between GAD-7 and TCI
subscales were also tested, and the demographic variables
(age, gender) were entered in the first step, and TCI
subscales were entered in the second step of the
hierarchical regression analyses. The results indicated that
just shyness subscale of Harm Avoidance was signicantly
predictive of GAD-7 scores.
DISCUSSION
The principal ndings of the present study were that GAD
patients exhibit higher HA and lower RD and SD scores
compared to healthy controls. These results were consistent
with a number of previous reports linking high HA (8-11),
low SD (9,12,13) and low RD (9,11) with GAD. However, the
relationship between personality and GAD seems to be
more complex. Personality features may not only
predispose an individual to the onset of anxiety, but may
also affect the expression of anxiety, or a separate process is
responsible for both personality factors and anxiety.
The risk of comorbidity with another psychiatric
disorder in GAD patients is estimated to be between 78%
and 90.4% (23,24). In a similar study conducted in the USA,
it has been reported that 66% of the GAD patients have
another concurrent psychiatric disorder such as major
depressive disorder, dysthymic disorder, alcohol use
disorder, simple phobia, and panic disorder (23). A study
conducted in Turkey has shown that major depression co-
morbidity rate in GAD patients was 83.7%. In this present
study, this rate was found to be 85% which is consistent
with the literature.
Cloninger et al. reported that the three personality traits
of Harm Avoidance, Self-Directedness, and Persistence
accounted for 23% of the variability in lifetime risk for
mood and anxiety disorders (25). In the present study, the
HA dimension with all the subscales found statistically and
significantly high compared to control group. In many
studies the correlation between HA and anxiety disorders
was shown and also the higher scores of HA has been found
to be related to the severity of the disorder (25-27). In
previous studies, anxiety disorder patients have been
considered as individuals with a temperament proles with
high HA, pessimism, shyness, and fearfulness. Even though
this situation can be considered as an inherited pattern in
behavior, high levels of HA is not a pre-condition in
diagnosis, since it is also seen in major depressive disorder
(25). However, in this present study, when we analyze the
GAD patients’ BDI scores whether they meet comorbid
depression criteria (based on Hisli’s BDI score of 17 and
above, which predicted depression in a Turkish university
student sample), we only had 6 patients who also had
comorbid depression and when we compare HA scores in
GAD patients compared to the GAD comorbid with
depression group, no signicant differeneces were found.
The result is not consistent with the previous reports (25-27),
most probably due to small sample size in GAD comorbid
depression group.
In addition to anxiety disorders, high levels of harm
avoidance behavior might be observed in adjustment
disorders. We already know that the serotonergic
mechanism of action which is important in pathophysiology
of the disorder is also related to harm avoidance. It is also
known that following pharmacotherapy of general anxiety
disorder and depressed patients with serotonergic agents, a
considerable decrease of HA scores in patients have been
documented. Abrams et al. reported that depressed
subjects, both before and after treatment, had signicantly
higher HA scores compared to healthy controls and
suggested that HA was trait-dependent in depression, and
Table 4: The results of the Hierarchical Multiple Regression
Model 1 B SE β
(Constant) 10.071 4.311
Age 0.055 0.087 0.071
Gender -2.831 1.790 -0.178
Model 2
(Constant) -2.021 6.476
Age -0.026 0.046 -0.033
Gender 1.122 0.942 0.070
NOVELTY SEEKING -0.135 0.106 -0.078
HARM AVOIDANCE 0.613 0.078 0.739**
REWARD DEPENDENCE -0.086 0.148 -0.035
PERSISTENCE -0.728 0.302 -0.167*
SELF-DIRECTEDNESS -0.133 0.090 -0.127
COOPERATIVENESS 0.152 0.108 0.087
SELF-TRANSCENDENCE 0.201 0.094 0.130*
R20.796
F 16.16**
*p<0.01, **p<0.05, Dependent variable: Generalized Anxiety Disorder Scale (GAD-7)

17
Journal of Mood Disorders Volume: 7, Number: 1, 2017 - www.jmood.org
Bal ZE, Solmaz M, Adali-Aker D, Akin E, Kose S
could be considered as a personality risk factor for
depression, which might also be valid for GAD patients
(28).
In terms of Novelty Seeking; Exploratory Excitability
subscale was statistically significantly lower and
impulsiveness subscale was statistically signicantly higher
compared to the controls. This ndings were in line with
previous studies. Piero et al. have suggested that higher NS
scores especially together with lower SD and RD scores,
might be associated with impulsiveness and might highlight
the relationship between impulsiveness and anxiety (9). In
terms of Reward Dependence scores; we found considerably
low RD scores compared to the control group. This result is
consistent with several previous studies (9,11,12). Also,
there are some studies showing higher RD scores (29) or
similar scores (30) in anxiety disorders patients compared
to the controls. Although no signicant differences were
found for Sentimentality and Dependence scores,
Attachment, and total Reward Dependence scores were
signicantly lower compared to controls. Persistence scores
were also significantly lower compared to the controls.
Cloninger’s view is that individuals with lower RD are
having difficulties such as social withdrawal, separation
and coldness in social interactions. Individuals with low
Persistence are lazy, motionless, undecided and untidy;
they rarely work for success and can quit very easily. In
previous studies Persistence used to be seen as a heredotary
disposition of the continuity of act even suppressed, related
to diligence, determination and has no relation with
anxiety.
In terms of character dimensions; it was reported that
GAD patients had lower Self-directedness scores in
previous studies (12,13). Due to fact that there was a
positive correlation between age and Self-Directedness and
Cooperativeness, we might conclude that character
dimensions evolve with age. No signicant differences were
found in the Self Acceptance subscale scores, but the
Responsibility, Purposefulness, Resourcefulness,
Congruent Second Nature subscales, and total Self-
Directedness scores were significantly lower in GAD
patients compared to the controls. These results were
consistent with the literature (12,13,26,31).
In previous studies, neuroticism was mentioned as a
pre-morbid personality trait, high HA and low SD were
mentioned as risk factors for depressive episodes and HA
might have been as a sub-dimension of temperament
starting from the early stage interacting and affecting the
evolution of SD in a negative manner (32).
Some studies have shown minor negative correlations
between Cooperativeness and anxiety (3,33). In our study,
there were no significant differences between total
Cooperativeness, Empathy, Helpfulness, Compassion,
Pure-Heartedness subscale scores. Only Social Acceptance
subscale scores were signicantly lower than the control
group. Individuals with low Social Acceptance scores are
impatient and they have a tendency to criticize other
people with different lifestyles and values.
In this present study, we found statistically signicant
and strong positive correlations between Harm Avoidance
scale and all subscales with BDI, BAI, GAD-7, and State
Anxiety and Trait Anxiety scores. This is consistent with the
current data and we might speculate that high levels of
harm avoidance might be a core feature of both anxiety and
depression. Similarly, individuals with poor emotional
regulation skills could be impaired at more moderate levels
of harm avoidance. Replication of these results using large
sample size and other clinical patient groups would be
critical to assess the generality of these ndings.
On the other hand, Self-Directedness scale (including
all of its subscales except for Self-acceptance) were
statistically significantly and negatively correlated with
BDI, BAI, STAI-I / STAI-II, and GAD-7 scores. This nding
was consistent with previous reports that Self-Directedness
was inversely correlated to anxiety (5,25). Individuals who
are low in SD feel that their attitudes, behavior, and choices
are determined by influences outside their control or
against their will and so can be anxious about each event.
The hypothesized relationship between GAD-7 scores
and TCI scales were tested in hierarchical multiple
regression. When demographic variables such as age and
gender were controlled Harm Avoidance, Persistence, and
Self-Transcendence and only shyness subscale of Harm
Avoidance were signicantly predictive of GAD-7 scores.
Our ndins support the notion that TCI can be instrumental
in both clinical and research purposes while evaluating
GAD patients and can be a predictor of the anxiety disorders
and its symptoms.
The present study has certain limitations. First,
temperament and character traits can also be affected by
personality disorders. We did not exclude patients who had
comorbid personality disorders. Second, it should be noted
that the study was carried out with a relatively small sample

18 Journal of Mood Disorders Volume: 7, Number: 1, 2017 - www.jmood.org
Temperament and character dimensions of personality in patients with generalized anxiety disorder
due to our hospital’s outpatient clinics inherent limitations.
Therefore, the conclusions should not be considered
denitive and further studies should be conducted in larger
patient samples. Despite these limitations, our findings,
especially predictive value of temperament and character
dimensions for generalized anxiety disorder would help
shape future discussions concerning the degree to which
temperamental traits are necessary or sufcient conditions
for anxiety disorder psychopathology.
In conclusion, our data suggest that enhanced
understanding of temperament–psychopathology relations
will have important implications for both assessment and
prevention of signicant psychiatric symptoms in patients
with generalized anxiety disorder.
References:
1. Sadock BJ, Sadock VA. Kaplan & Sadock’s Concise Text book of
Clinical Psychiatry. Lippincott Williams and Wilkins. 2008:264-5.
2. Brandstrom S, Schlette P, Przybeck TR. Swedish normative data
on personality using the temperament and character inventory.
Compr Psychiatry. 1998;39:122-8. [CrossRef]
3. Tanaka E, Sakamoto S, Kijima N, Kitamura T. Different
personalities between depression and anxiety. J Clin Psychology.
1998;54:1043-51. [CrossRef]
4. Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model
of temperament and character. Archives of General Psychiatry.
1993;50:975-90. [CrossRef]
5. Matsudaira T, Kitamura T. Personality traits as risk factors of
depression and anxiety among Japanese students. Journal of
Clinical Psychology. 2006;62(1):97-109. [CrossRef]
6. Kose S. A psychobiological model of temperament and character:
TCI. New Symposium. 2003;41(2):86-97.
7. Cloninger CR, Svrakic NM, Svrakic DM. Role of personality self-
organization in development of mental order and disorder. Dev
Psychopathol. 1997;9(4):881-906. [CrossRef]
8. Allgulander C, Cloninger CR, Przybeck TR, Brandt L. Changes
on the Temperament and Character Inventory after paroxetine
treatment in volunteers with generalized anxiety disorder.
Psychopharmacology Bulletin. 1997;34(2):165-6.
9. Pierò A. Personality correlates of impulsivity in subjects with
generalized anxiety disorders. Compr Psychiatry. 2010;51(5):538-
45. [CrossRef]
10. Rettew DC, Doyle AC, Kwan M, Stanger C, Hudziak JJ. Exploring
the boundary between temperament and generalized anxiety
disorder: A receiver operating characteristic analysis. Journal of
Anxiety Disorders. 2006;20(7):931-45. [CrossRef]
11. Starcevic V, Uhlenhuth EH, Fallon S, Pathak D. Personality
dimensions in panic disorder and generalized anxiety disorder. J
Affect Disord. 1996;37:75-9. [CrossRef]
12. Cloninger CR. A practical way to diagnosis personality disorder: a
proposal. J Pers Disord. 2000;14(2):99-108. [CrossRef]
13. Ball S, Smolin J, Shekhar A. A psychobiological approach to
personality: examination within anxious outpatients. J Psychiatr
Res. 2002;36(2):97-103. [CrossRef]
14. American Psychiatric Association (2013). Diagnostic and statistical
manual of mentaldisorders (5th ed.). Arlington, VA: American
Psychiatric Publishing. [CrossRef]
15. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for
assessing generalized anxiety disorder: the GAD-7. Arch Intern
Med. 2006 May 22;166(10):1092-7. [CrossRef]
16. Ulusoy M, Sahin NH, Erkmen H. Turkish version of the Beck
Anxiety Inventory: Psychometric properties. J Cogn Psychother.
1998;12:163-72.
17. Öner N, Le Compte A. Durumluk Sürekli Kaygı Envanteri El Kitabı:
İstanbul, Boğaziçi Üniversitesi Yayınları, 1983.[Turkish]
18. Kose S, Sayar K, Ak I, Aydin N, Kalelioglu U, Kirpinar I, et al.
Turkish version of the TCI: reliability, validity, and factorial
structure. Klinik Psikofarmakoloji Bulteni - Bulletin of Clinical
Psychopharmacology. 2004;14(3):107-31.
19. Konkan R, Senormanci O, Guclu O, Aydin E, Zungur MZ. Validity
and Reliability Study for the Turkish Adaptation of the Generalized
Anxiety Disorder-7 (GAD-7) Scale Archives of Neuropsychiatry.
2013;50:53-8. [CrossRef]
20. Savaşır I, Şahin NH. (1997). Bilişsel- Davranışçı Terapilerde
Değerlendirme: Sık Kullanılan Ölçekler. Ankara: Türk Psikologlar
Derneği Yayınları. [Turkish]
21. Hisli N. The Validity and Reliability of Beck Depression Scale
For University Students. Psychology Bulletin 1988;7(23):3-13.
[Turkish]
22. Beck AT, Steer RA. Beck Anxiety Inventory Manual: San Antonio,
TX, Psychological Corporation, 1993.
23. Wittchen HU, Zhao S, Kessler RC, Eaton WW. DSM-III-R
generalized anxiety disorder in the National Comorbidity Survey.
Arch Gen Psychiatry. 1994;51:355-64. [CrossRef]
24. Garyfallos G, Adamopoulou A, Karastergiou A. Psychiatric
comorbidity in Greek patients with generalized anxiety disorder.
Psychopathology. 1999;32:308-18. [CrossRef]
25. Cloninger CR, Zohar AH, Hirschmann S, Dahan D. The
psychological costs and benefits of being highly persistent:
personality profiles distinguish mood disorders from anxiety
disorders. J Affect Disord. 2012;136(3):758-66. [CrossRef]
26. Nyman E, Miettunen J, Freimer N, Joukamaa M, Mäki P, Ekelund
J, et al. Impact of temperament on depression and anxiety
symptoms and depressive disorder in a population-based birth
cohort. J Affect Disord. 2011;131(1-3):393-7. [CrossRef]
27. Jylhä P, Isometsä E. Temperament, character and symptoms
of anxiety and depression in the general population. European
Psychiatry. 2006;2(6):389-395. [CrossRef]

19
Journal of Mood Disorders Volume: 7, Number: 1, 2017 - www.jmood.org
Bal ZE, Solmaz M, Adali-Aker D, Akin E, Kose S
28. Abrams KY, Yune SK, Kim SJ, Jeon HJ, Han SJ, Hwang J, et al.
Trait and state aspects of harm avoidance and its implication
for treatment in major depressive disorder, dysthymic disorder,
and depressive personality disorder. Psychiatry Clin Neurosci.
2004;58(3):240-8. [CrossRef]
29. Cloninger CR. A unified biosocial theory of personality and its role
in the development of anxiety-states. Psychiatric Developments.
1986;4:167-226.
30. Lischetzke T, Eid M. Is attention to feelings beneficial or detrimental
to affective wellbeing? Mood regulation as a moderator variable.
Emotion. 2003;3:361-77. [CrossRef]
31. Lu X, Chen Z, Cui X, Uji M, Miyazaki W, Oda M, et al. Effects
of Temperament and Character Profiles on State and Trait
Depression and Anxiety: A Prospective Study of a Japanese Youth
Population. Depress Res Treat. 2012;2012:604684. [CrossRef]
32. Hansenne M, Reggers J, Pinto E, Kjiri K, Ajamier A, Ansseau M.
Temperament and character inventory (TCI) and depression. J
Psychiatr Res. 1999;33(1):31-6. [CrossRef]
33. Pélissolo A, André C, Pujol H, Yao SN, Servant D, Braconnier A,
Orain-Pélissolo S, Bouchez S, Lépine JP. Personality dimensions in
social phobics with or without depression. Acta Psychiatr Scand.
2002;105(2):94-103. [CrossRef]