Akiskal Unplugged, Part II - Temperament

To continue where we left off ...

The subject of temperament came up in passing in Hagop Akiskal’s talk to DBSA San Diego that I attended on Monday evening. Temperament is very central to Akiskalology and the art of understanding what is really going on with our moods. Unfortunately, Dr Akiskal’s audience got too involved interrupting his presentation for generic Ask-the-doctor questions for him to string together two sentences in a row on the topic.

This is not a criticism of those who turned up on Monday. The party line that gets drummed into our heads by lesser minds tends to blind us to the thinkers and the visionaries in our midst, and I plead guilty on serial counts to this. Let me rewind the clock to spring, 2002:

I was in Philadelphia attending my very first American Psychiatric Association annual meeting. Twenty thousand psychiatrists and industry hacks (it’s often hard to tell the difference) were in town for the six-day extravaganza. Biological psychiatry was singing high praises to itself. New meds were coming on the market and the best brains in the business were figuring out smarter ways to use the current ones. Even the highly critical commentary supported the basic paradigm - namely that there was a pharmaceutical answer for just about everything that went wrong beneath the hood. Even if we didn’t yet have all the answers, they were well within our reach.

So it was that I entered a dark and crowded room to hear Dr Akiskal for the very first time. Although I was familiar with the name, I only had the barest superficial knowledge of his work. I had been expecting him to elaborate on why some forms of depression should be regarded as bipolar, when a bunch of “It’s Greek to me” stuff came up on his PowerPoint.

Literally. Up went slides of the Greek four humors (or temperaments), such as “melancholia” (literally meaning black bile).

What did this have to do with psychiatry? was my first reaction. Then again, I rationalized, Akiskal was probably just setting the scene. It’s a recurring problem with medical doctors who probably took arts courses in their undergraduate years. But then he started elaborating on the four humors. Not only that, he came up with his own version of the four humors. And not only that, he came up with evolutionary reasons for the four humors.

Okay, this has gone far enough, I thought. Enough, already, with this rambling prelude on ancient history. Let’s cut to the fugue. I’m here to find out about depression and bipolar. I won’t say I was disappointed. Rather, I was confused, like listening to a difficult piece of music for the first time. I had a lot of stuff to report from that first APA meeting, but Akiskal’s presentation wasn’t one of them.

Such are the pitfalls to being deaf-dumb-and-blind to the thinkers and visionaries in our midst.

So here is what Akiskal went into in depth talking to psychiatrists in Philadelphia in 2002 and that he touched on talking to patients and family members two days ago in San Diego:

By temperament, Akiskal is referring to heritable “stable behavior traits with strong affective coloring,” throughout life. Thus, downbeat may be your baseline personality “trait”, which is a very different proposition than being in a temporarily depressed “state,” but the two are related. So much so that understanding how this state-trait dynamic works for us is crucial - absolutely crucial - to our wellness.

Drawing upon the work of the German psychiatrist Ernst Kretschmer writing in the 1930s, Akiskal points out that temperament and various related personality constructs may not only set us up for mood disorders, but can be considered as sharing the same continuum, from healthy to extreme (though much more research is needed to bear this out).

And, of course, wherever you find Akiskal, you find Kraepelin. As Akiskal describes it in a 2010 article:

The concept that different kinds of temperament are constitutionally based types of behavior can be traced back to the ancient humoral theory of Hippocrates. About 90 years ago, Kraepelin described four basic affective dispositions (depressive, manic, cyclothymic and irritable), which he believed to be subclinical forms and many times the precursors of major affective psychoses.

Moreover, these temperaments can be found in the blood relatives of those with manic-depression (which would include recurrent depression as well as bipolar). Indeed, as Akiskal pointed out two nights ago, it’s the relatives of bipolar patients who tend to benefit from having bipolar characteristics (namely in a genetically dilute form), not necessarily the patients (who unfortunately get hit with the illness full strength). Indeed, relatives and bipolar IIs are more likely to have creative accomplishments (borne out in surveys he has conducted) rather than those with bipolar I, who have far too much to contend with.

In Philadelphia, Akiskal substituted “hyperthymic” temperament for “manic,” and these are the ones who obviously benefit from having a “little bit” of bipolar. These are your exuberant upbeat types, highly energetic and super-confident, out to conquer the world. Hyperthymic is the “trait.” By contrast, “hypomanic” is the “state.”

To very loosely translate Akiskal, imagine two individuals giving very dazzling presentations in a large room. One is on the way to a brilliant career. The other is headed for a crash. Same behavior, very different result. The naturally upbeat individual will power on through thick and thin, and be abundantly rewarded. The temporarily upbeat individual is living on borrowed time.

But it’s much more complicated than that. Even hyperthymic individuals can go over the top (just ask Monica Lewinsky’s erstwhile boyfriend). And hyperthymia overlayed with a depressive state is playing with fire.

Confused? So was I back in Philadelphia in 2002.

Much more to come ...