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Comprehensive Psychiatry 53 (2012) 1096 1102

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Temperament and character traits in patients with bipolar disorder and

associations with attempted suicide
Gkhan Sarsoy, mer Faruk Kaar, Ozan Pazvantolu, Arif ztrk, Il Zabun Korkmaz,
Birsen Kocamanolu, mer Bke, Ahmet Rifat Sahin
Psychiatry Department, Ondokuz Mayis University School of Medicine, Tp Fakltesi Psikiyatri Anabilim Dal, 55139 Samsun, Turkey

Abstract
Objective: This study was intended to investigate temperament and character traits in bipolar disorder patients with or without a history of
attempted suicide.
Methods: One hundred nineteen patients diagnosed with euthymic bipolar disorder based on Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, and with no accompanying Axis I and II comorbidity, and 103 healthy controls were included.
Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I and II disorders were used to
exclude Axis I and II comorbidity. Temperament and character traits of bipolar patients with a history attempted suicide (25.2%, n = 30) or
without (74.8%, n = 89) and of the healthy volunteers were determined using the Temperament and Character Inventory. The association
between current suicide ideation and temperament and character traits was also examined.
Results: Bipolar patients with or without a history of attempted suicide had higher harm avoidance (HA) scores compared with the healthy
controls. Persistence scores of bipolar patients with no history of attempted suicide were lower than those of the healthy controls. Selfdirectedness (SD) scores of the bipolar patients with a history of attempted suicide were lower than those of patients with no such history.
Self-transcendence scores of bipolar patients with no history of attempted suicide were lower than those of both the healthy controls and of
those patients with a history of attempted suicide. A positive correlation was determined between current suicidal ideation scale scores and
HA, and a negative correlation between SD and cooperativeness was determined.
Conclusions: High harm avoidance may be a temperament trait specific to bipolar disorder patients. However, it may not be correlated with
attempted suicide in such patients. These may have low persistence, high SD and low self-transcendence temperament and character traits
that protect against attempted suicide. Harm avoidance, SD, and cooperativeness may be correlated with current suicidal ideation.
2012 Elsevier Inc. All rights reserved.

1. Introduction
Studies investigating temperament and character traits in
bipolar disorder patients have grown rapidly in recent years.
The Temperament and Character Inventory (TCI) is
frequently used in these studies. The most frequently
identified temperament traits in bipolar disorder measured

Corresponding author. Tel.: +90 362 3121919/3777; fax: +90 362

4576041.
E-mail addresses: gokhansarisoy@gmail.com (G. Sarsoy),
ofarukkacar@gmail.com (.F. Kaar), ozanpazvantoglu@gmail.com
(O. Pazvantolu), dr.arifozturk@gmail.com (A. ztrk),
isilzabun@hotmail.com (I.Z. Korkmaz), birsenkocaman@yahoo.com
(B. Kocamanolu), omerbk@omu.edu.tr (. Bke), arsahin@omu.edu.tr
(A.R. Sahin).
0010-440X/$ see front matter 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.comppsych.2012.05.002

by this inventory are high harm avoidance (HA) and low

persistence (PS) [1-11]. Findings regarding novelty seeking
(NS) and reward dependence (RD) temperament traits are
contradictory [1-3,5-9,11,12]. The most commonly determined character traits are low self-directedness (SD), low
cooperativeness (CO), and high self-transcendence (ST) [49,11,12]. Axis I and II disorders accompanying bipolar
disorder may affect temperament and character traits [8,12].
Axis I and II disorders accompanying bipolar disorder were
not excluded in any of the previous studies in question.
Suicide ideation, attempted suicide, and completed
suicide are frequently seen in bipolar disorder. Eighty
percent of bipolar patients have suicidal ideation during their
lives, 25% to 50% attempt suicide, and 4% to 19% lose their
lives as the result of suicide [13-15]. Suicidal ideation is a
risk factor for attempted suicide and attempted suicide for

G. Sarsoy et al. / Comprehensive Psychiatry 53 (2012) 10961102

completed suicide [14,16-25]. Studies of social sampling and

psychiatric diseases have determined a correlation between
suicidal behavior (ideation, attempted, or completed suicide)
and several personality traits, such as neuroticism, openness,
psychoticism, perfectionism, dependency, cyclothymic temperament, perceptual aberration, interpersonal aversiveness,
unconventionality, hopelessness, self-criticism, extroversion, irritability, aggression, hostility, impulsivity, high
NS, high HA, high PS, low RD, low SD, low CO, and
high ST [13,16,26-35].
In addition to Axis I and II comorbidity, early sexual
and physical abuse; a family history of suicidal behavior;
rapid cycling; depressive and mixed episodes; insomnia;
anxiety; female sex; and past suicide attempts and
personality traits such as impulsivity, anger, aggressiveness, hopelessness, and pessimism are also risk factors for
suicide attempts and ideation [15,17]. The number of
studies in the literature investigating the temperament and
character traits of bipolar disorder patients with a history of
attempted suicide using TCI is limited [12,36,37].
Engstrm et al [36] determined high HA and high RD in
bipolar patients with previous attempted suicide compared
with those with no such history. They determined no difference in terms of character traits. In comparison with
healthy controls, they determined high HA, low PS, and
low SD in bipolar patients with a history of attempted
suicide and low RD and low CO in bipolar patients with no
such history. They concluded that HA and PS temperament
traits were a risk factor for attempted suicide, whereas
Sayin et al [12] and Joyce et al [37] reported high HA as a
risk factor. To the best of our knowledge, there are no
previous studies examining the correlation between current
suicide ideation and temperament and character traits in
bipolar disorder patients.
This study had 2 aims: the first was the determination of
temperament and character traits of bipolar patients with or
without a history of attempted suicide. The second was to
examine the correlation between current suicidal ideation
and temperament and character traits.
2. Materials and methods
2.1. Sample and procedures
Two hundred twenty-two volunteers, 119 bipolar disorder
patients, diagnosed based on Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, diagnostic
criteria and determined as euthymic at clinical examination,
applying to the Ondokuz Mays University Faculty of
Medicine Psychiatry Department Mood Disorders unit,
Turkey, between July 2009 and December 2011, and 103
healthy controls were included in the study. Bipolar patients
who met criteria for a manic, mixed, hypomanic, or
depressive episode at clinical interview were excluded.
Structured Clinical Interview for Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV),

1097

Axis I (SCID-I) and Axis II disorders were administered to

all patients and the control group, and those identified as
having Axis I and II disorder were excluded. Inclusion
criteria were willingness to participate, literacy, older than 18
years, and having no medical disease that might prevent
comprehension of and responding to the scale administered.
A direct questioning technique, such as used by Gao et al
[38] in their study, was used to identify patients with a
history of attempted suicide: Have you ever attempted
suicide? If patients answered yes, then they were asked
when the suicide attempt occurred, how it was carried out
(such as overdosing on medication, cutting, hanging, or other
means) and what the outcome was (such as stomach
pumping, wound suturing, coma, hospitalization, etc). As
other variables, collateral information from significant
other(s) was also taken into consideration during the
assessment of previous attempts. This evaluation showed
that 25.2% (n = 30) of patients had attempted suicide at least
once, whereas 74.8% (n = 89) had no history of attempted
suicide. The TCI was administered to all bipolar patients and
healthy controls to determine temperament and character
traits. The Suicide Ideation Scale was administered to bipolar
patients with or without a history of attempted suicide to
determine suicide ideations.
The study was conducted in accordance with the ethical
standards of the Helsinki Declaration of 2000. Informed
consent was obtained from all subjects after the procedure
had been fully explained.
2.2. Materials
2.2.1. Sociodemographic data form
The Psychiatry Association of Turkey Mood Disorders
Study Group bipolar disorder patient recording and
monitoring system [39] is used for recording bipolar
disorder patients in our mood disorders unit. Data
regarding patients' ages, sex, years of education, marital
status, socioeconomic status, and place of residence were
taken from this form.
2.2.2. Temperament and Character Inventory
This is a 240-item self-report questionnaire, developed
by Cloninger [40] according to a psychobiological model
of temperament and character. The TCI is a 240-item selfadministered questionnaire that measures the 3 character
dimensions (SD, CO, and ST) and the 4 temperament
dimensions (NS, HA, RD, and PS). The 240 items are
answered yes or no by the patient. The patients and
controls completed a Turkish version of the 240-item selfquestionnaire at the end of the psychiatric interview. The
Turkish-TCI has been validated by Kose et al [41].
2.2.3. Suicide ideation scale
Suicide ideation scale was developed by Linehan and
Nielsen [42]. Validity and reliability in Turkey were
performed by Dilbaz et al [43]. Patients answer yes or

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G. Sarsoy et al. / Comprehensive Psychiatry 53 (2012) 10961102

no to the 17 items. The highest possible score is 17. The

scale measures suicide ideation within the previous week.
High scores indicate increased suicide ideation.
2.2.4. Structured Clinical Interview for DSM-IV Axis
I disorders
First et al [44] developed a structured interview chart
that would permit the diagnosis of Axis I disorders
according to DSM-IV diagnostic criteria. Axis I disorders
are investigated for 2 different periods (life-long and
within the preceding month). The clinical version of SCIDI was translated into Turkish by zkrkil et al [45],
and modifications and safety studies have been conducted
for Turkey.
2.2.5. Structured Clinical Interview for Diagnostic and
Statistical Manual of Mental Disorders, Revised Third
Edition, personality disorder
Spitzer et al [46] developed this form for Diagnostic
and Statistical Manual of Mental Disorders, Third Edition;
it has been revised for Diagnostic and Statistical Manual
of Mental Disorders, Revised Third Edition, and is
currently used for personality disorders as described in
the second axis. The Turkish version was developed by
Sorias et al [47], and relevance and reliability studies have
been conducted.
2.3. Statistical analysis
Statistical analysis was carried out using SPSS 16.0 for
Windows (SPSS, Chicago, IL). The 2 test was used to
compare categorical variables. The Student t test was used
for comparison of 2 groups' data obtained by measurement, and analysis of variance (ANOVA) (1-way) was
used to compare 3 groups. As variances for the post hoc
test were equal, the Tukey test was used. Cohen's method
was used to determine effect size in comparison of 2
groups. For this index, cutoffs of 0.2, 0.5, and 0.8 are, by
convention, interpreted as small, medium, and large effect
sizes, respectively. Effect size index (as partial 2) for 1way ANOVA is computed using a general linear model
procedure. For this index, cutoffs of 0.01, 0.06, and 0.14
are, by convention, interpreted as small, medium, and
large effect sizes, respectively. Pearson correlation coefficients were calculated to examine the association
between temperament and character inventory scores and
suicide ideation scale score for all bipolar patients and for
bipolar patients with past suicide attempts. Correlation
coefficients between 0.30 and 0.49 were regarded as low;
those between 0.50 and 0.69, as moderate; those between
0.70 and 0.89, as high; and those between 0.90 and 1.00,
as very high [48]. The data obtained by measurement
were expressed as arithmetical mean SD, and those
obtained by counting, as percentages. P b .05 was
regarded as significant.

Table 1
Comparison of bipolar and control group sociodemographic characteristics

Sex
Female
Male
Mean age (mean SD)
Education
(years spent in)
(mean SD)
Marital status
Married
Single
Socioeconomic status
Low
Middle
High
Living in
Province
Subprovince
Village
Total

Bipolar patients
(n = 119), %

Controls
(n = 103), %

2/t

84 70.6
35 29.4
38.18 13.00

74 71.8
29 28.2
36.84 11.65

0.003

NS

0.803

NS

11.29 3.45

12.05 3.80

1.540

NS

58 48.7
61 51.3

62 60.2
41 39.8

2.474

NS

4 3.4
108 90.7
7 5.9

11 10.7
89 68.4
3 2.9

5.575

NS

84 70.6
23 19.3
12 10.1
119 100.0

69 67.0
24 23.3
10 9.7
103 100.0

0.523

NS

Level of significance P b .05. Abbreviation: NS, nonsignificant.

3. Results
3.1. Comparison of the bipolar disorder and control groups
in terms of sociodemographic characteristics
There was no difference between the bipolar disorder and
control groups in terms of sociodemographic variables (age,
sex, years spent in education, marital status, socioeconomic
level, and place of residence) (P N .05) (Table 1). At least 1
previous suicide attempt was determined in 25.2% (n = 30)
of the patients with bipolar disease. No difference in terms of
sociodemographic variables was determined between bipolar
disorder patients with or without a history of attempted
suicide (P N .05).
3.2. Comparison of the bipolar disorder and control groups
in terms of temperament and character traits
Harm avoidance scores were higher in the bipolar
disorder group compared with the control group (P =
.002), and the difference was small (effect size, 0.42).
Persistence scores were lower (P = .005), and the difference
Table 2
Comparison of bipolar disorder and control group TCI scores

NS
HA
RD
PS
SD
CO
ST

Bipolar (n = 119) Controls (n = 103) t

18.30 4.77
19.17 5.81
14.23 2.74
4.44 1.85
26.08 7.13
27.28 5.90
18.09 6.50

NS
.002
0.42 a
NS
.005 0.38 a
NS
NS
NS

Significance, P b .05.
a
Small effect size.

18.04 5.28
16.77 5.69
13.88 3.29
5.15 1.87
25.93 6.89
26.93 6.22
19.28 5.22

0.390
3.099
0.868
2.829
0.161
0.434
1.511

Effect sizes

G. Sarsoy et al. / Comprehensive Psychiatry 53 (2012) 10961102

1099

Table 3
Comparison of bipolar patients with or without a history of attempted suicide in terms of TCI scores

NS
HA
RD
PS
SD
CO
ST

Controls (n = 103)(1)

Suicide (n = 30)(2)

Nonsuicide (n = 89)(3)

18.04 5.28
16.77 5.69
13.88 3.29
5.15 1.87
25.93 6.89
26.93 6.22
19.28 5.22

17.07 3.70
19.73 6.28
13.73 2.75
5.07 1.44
23.17 7.24
27.33 4.96
20.60 5.91

18.72 5.28
18.98 5.67
14.40 2.73
4.22 1.93
27.07 6.85
27.27 6.21
17.25 6.50

1.301
4.980
0.935
6.403
3.576
0.095
4.818

NS
.008
NS
.002
.030
NS
.009

Effect size ( 2)

Post hoc (Tukey)

0.13 a

1/2,1/3

0.06 a
0.17 b

1/3
2/3

0.15 b

1/3, 2/3

Significance, P b .05; 2, partial 2 for ANOVA results.

a
Medium effect size.
b
Large effect size.

was small (effect size, 0.38). No difference was determined

between the 2 groups in terms of others temperament and
character traits (P N .05) (Table 2).
3.3. Comparison of the bipolar disorder patient groups with
or without a history of attempted suicide in terms of
temperament and character traits
No difference was determined between the 3 groups in
terms of NS and RD temperament and CO character traits. A
difference was determined in terms of the temperament traits
HA (P = .008; moderate effect size, 0.13) and PS (P = .002;
moderate effect size, 0.06) and the character traits SD (P =
.030; large effect size, 0.17) and ST (P = .009; large effect
size, 0.15). Looking at which groups the differences
originated from, HA scores were higher in bipolar disorder
patients with or without a history of attempted suicide than in
the controls. Persistence scores in the nonsuicide attempt
group were lower than those of the controls. Selfdirectedness scores in the suicide attempt group were
lower than those of the nonsuicide attempt group. Selftranscendence scores in the nonsuicide attempt group were
lower than in both the suicide attempt and control groups
(Table 3).
3.4. Comparison of suicide ideation scale scores in bipolar
disorder patients with or without a history of attempted suicide
Current suicide ideation scores were higher in the
attempted suicide group (P = .003), and the difference was
moderate (effect size, 0.61) (Table 4).
Table 4
Comparison of patients with or without a history of attempted suicide in
terms of suicide ideation scores
Suicide
attempt
(n = 30)

Non-suicide t
attempt
(n = 89)

Suicide ideation scale 6.20 3.85 3.99 3.35

(mean SD)
Significance, P b .05.
a
Medium effect size.

Effect
size

3.009 .003 0.61 a

3.5. Correlation of suicide ideation scale scores with TCI

scores of the entire bipolar patient group and the bipolar
patient group with a history of attempted suicide
Suicide ideation scale scores in the entire bipolar patient
group (n = 119) had a low, positive correlation with HA
scores, a moderate negative correlation with SD scores, and a
low negative correlation with CO scores (Table 5). Suicide
ideation scale scores in the bipolar patient group (n = 30)
with a history of attempted suicide were moderately
negatively correlated with SD scores and had a low negative
correlation with CO scores (Table 6).
4. Discussion
The most frequently repeated finding, in terms of
temperament characteristics, in bipolar patients in comparative studies with healthy controls is high HA [1-11].
Individuals high in HA tend to be cautious, careful, fearful,
tense, apprehensive, nervous, timid, doubtful, discouraged,
insecure, passive, negativistic, or pessimistic, even in
situations that do not normally worry other people [49].
We also determined higher HA in bipolar disorder patients
compared with the controls. Furthermore, HA was higher in
the bipolar patient groups with and without history of
attempted suicide compared with the controls. No difference was determined between the attempted suicide and
nonsuicide patient groups in terms of HA scores. In contrast
to our study, Engstrm et al [36] determined higher HA in
bipolar patients with a history of attempted suicide
compared to those with no such history. In addition,
Sayin et al [12] and Joyce et al [37] suggested that the HA
temperament trait is a risk factor for attempted suicide in
bipolar patients. These findings conflict with ours. However, we did determine a correlation between current
suicidal ideation and HA. Further studies are needed to
establish the correlation between the high HA temperament
trait and attempted suicide and suicidal ideation in bipolar
disorder patients.
Another frequent temperament trait in bipolar disorder is
low PS [2,3,9,11]. We also determined lower PS in bipolar
patients compared with the healthy controls. However, in our

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G. Sarsoy et al. / Comprehensive Psychiatry 53 (2012) 10961102

Table 5
Correlations between TCI and suicide ideation scale score for all bipolar patients (n = 119)

Suicide ideation
scale

NS

HA

RD

PS

SD

CO

ST

r = 0.127
P = .167

r = 0.315
P = .000

r = 0.114
P = .219

r = 0.039
P = .677

r = 0.582
P = .000

r = 0.336
P = .000

r = 0.241
P = .008

Coefficients greater than or equal to 0.30 are shown in bold.

study, the temperament trait PS in the group with a history of

attempted suicide was no different from the healthy controls,
whereas that of the group with no history of attempted
suicide was lower than that of the controls. This suggested
that the low PS temperament trait determined in bipolar
patients in the literature may be correlated with patients with
no attempted suicide. People with a low PS temperament are
inactive and indolent, give up easily, and are modest and
underachieving, quitting, and pragmatic; people with a high
PS temperament trait are industrious and diligent, hardworking, ambitious and overachievers, persevering, and perfectionist [49]. Therefore, lower temperament traits such as
industriousness, perseverance, and perfectionism in bipolar
patients, a group with a low PS temperament trait who have
to live with a major psychiatric disease such as bipolar
disorder, may protect against suicide attempts.
Findings in the literature regarding NS and RD
temperament traits in bipolar patients are contradictory.
Various studies have reported these temperament traits as
being higher compared with healthy controls [1,2,6,8,9] or
lower [3,4,9] or have determined no difference [7,8,11,12].
There was no difference in our study in terms of NS and RD
between bipolar disorder patients and healthy controls. In
addition, no difference was determined in comparison of the
bipolar patients groups with or without a history of attempted
suicide and the healthy control group in terms of NS and RD
temperament traits. This finding of ours is in agreement with
the study of Engstrm et al [36]. These results suggest that
the temperament traits in question are not correlated with
attempted suicide in bipolar patients.
Character traits frequently determined in studies comparing bipolar patients with healthy controls are low SD [59,11,12], low CO [4-6,8,9,12], and high ST [6-8]. People
with a low SD character trait are immature, weak, fragile,
blaming, destructive, ineffective, irresponsible, and unreliable. People with a low CO character trait are self-absorbed,
intolerant, critical, unhelpful, revengeful, and opportunistic.
People with a high ST character trait are wise and patient,
creative, and self-forgetful and at one with the universe
[40,49]. It has been suggested that low SD and CO are
indicators of immature defense mechanisms and personality

disorder [50-53]. None of the studies in the literature

investigating temperament and character traits in bipolar
disorder patients excluded Axis I and II comorbidity.
Moreover, Sayin et al [12] determined low SD and CO in
bipolar patients accompanying personality disorder. Nery et
al [8] determined low SD in bipolar patients with anxiety
disorder comorbidity. In 3 studies in which high ST was
determined [6-8], low SD and low CO accompanied the
picture. According to Cloninger's theory of character [49],
high ST permits mature creativity and spirituality in the
presence of high SD and high CO. High ST being
accompanied by low SD and CO is an indicator of
immaturity and schizotype. Loftus et al [7] suggested that
high ST accompanying low SD may be an indicator of
residual psychotic symptoms. No difference was determined
in our study between the bipolar patients and healthy
controls in terms of character traits. In the light of the above
findings, the fact that the patients whom we enrolled were
euthymic and that Axis I and II comorbid disorders were
excluded may explain this result. According to the results of
our study, which permitted an analysis more sterilized from
confusing factors with the exclusion of comorbidity, it may
be suggested that character traits of bipolar disorder patients
do not differ from those of healthy individuals. In addition,
Axis I and II comorbidity in bipolar disorder patients is a risk
factor for attempting suicide and ideation [15]. Therefore, the
exclusion of Axis I and II comorbidity in our study is also
significant in terms of accurate determination of character
traits of bipolar disorder patients with a history of attempted
suicide or suicidal ideation.
Engstrm et al [36] determined lower SD in bipolar
patients with a history of attempted suicide compared with
healthy controls. As stated above, Axis I and II comorbidity
was not excluded in this study. Self-directedness scores of
the attempted suicide bipolar group were not different to
those of the healthy controls but were lower than those of the
group with no history of attempted suicide. This suggested
that a group with a greater SD character trait in bipolar
disorder patients may be more resistant to attempting suicide.
Although the SD of patients with a history of attempted
suicide was not different to those of healthy individuals, a

Table 6
Correlations between TCI and suicide ideation scale scores for bipolar patients with attempted suicide (n = 30)

Suicide ideation scale

NS

HA

RD

PS

SD

CO

ST

r = 0.204
P = .279

r = 0.206
P = .275

r = 0.086
P = .650

r = 0.122
P = .521

r = 0.659
P = .000

r = 0.454
P = .012

r = 0.194
P = .303

Coefficients greater than or equal to 0.30 are shown in bold.

G. Sarsoy et al. / Comprehensive Psychiatry 53 (2012) 10961102

group with high SD in individuals having to live with such a

major disorder as bipolar disorder may be resistant to suicide
thanks to this character trait because people with high SD
have high self-esteem, an internal locus of control, and high
problem-solving capacities and coping behaviors [40,49].
Bipolar patients with less SD character trait may despair
more easily and behave suicidally because of problemsolving and coping behavior difficulties in the face of
difficulties created by the disease. We determined that the
group with no history of attempted suicide had lower ST
character trait scores compared with both the healthy
controls and also the group with a history of attempted
suicide. People with low ST are impatient, unimaginative,
and self-conscious and exhibit pride and lack of humility.
They cannot tolerate ambiguity, uncertainty, or surprises.
Instead, they strive for more control over almost everything.
Low scorers on this dimension may impress others as
pretentious. Individuals low in ST are often admired in
Western societies for their rational, scientific, and material
success. They may have difficulty accepting suffering and
death [40,49]. People with a low ST character trait are
pretentious, individualistic, controlling, and self-conscious,
and their having difficulty in accepting death may be a
character trait that protects against suicide.
Bipolar patients with a history of attempted suicide had
higher current suicide ideation scores than those with no
such history. This suggested that there may be a group within
bipolar patients with a predisposition to suicidal behavior,
even in euthymic periods. We, therefore, investigated the
correlation between suicide ideation and temperament and
character separately for bipolar patients as a whole and also
for patients with a history of attempted suicide. We
determined a positive correlation between current suicide
ideation and HA scores in the full bipolar patient group and a
negative correlation between SD and CO scores. In the
bipolar group with a history of attempted suicide, there was a
negative correlation between current suicide ideation and SD
and CO character traits. People with a low CO character trait
are socially intolerant, critical, unhelpful, vengeful, and
destructive [49]. In contrast to temperament traits, character
traits are open to development throughout life [40,49].
Fountoulakis et al [54] reported that suicidal behavior
(ideation, attempted suicide, completed suicide) in bipolar
patients is correlated with poor psychosocial adaptation,
poorer coping strategies, recent psychosocial stress, occupational or interpersonal problems with spouse or romantic
partner, greater personal history of early traumatic stressors
and sexual abuse, early parental separation, lower selfesteem, and more external locus of control. Problems of this
kind are clearly closely correlated with low SD and low CO.
Psychotherapeutic approaches (personal, interpersonal, family-focused, cognitive-behavioral, problem solving, and
communication skills, etc) directed toward the development
of such character traits may be useful in preventing suicidal
behavior (ideation, attempted suicide, completed suicide) in
bipolar disorder patients.

1101

The new study of Cloninger et al [55] notes the clinical

significance of the determination of multidimensional
temperament and character profile by investigating the
interactions of temparement and character traits. Bearing in
mind our study findings, the determination of multidimensional temperament and character profiles in bipolar disorder
patients with attempted suicide or suicidal ideation (particularly regarding interactions between PS, SD, CO, and ST)
may be important in the monitoring and treatment of these
patients. This should be a point of focus in future studies.
In conclusion, a low PS temperament trait and high SD,
high CO, and low ST character traits in bipolar disorder
patients with no accompanying Axis I and II comorbidity may
protect against suicidal behavior (ideation, attempted suicide).
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