F. Gokmen1 · K. Altinbas2 · A. Akbal1 · M. Celik3 · Y. Savas1 · E. Gökmen4 · H. Reşorlu1 · A. Karaca5

1 Department of Physical Medicine and Rehabilitation, Medical School, 

Canakkale Onsekiz Mart University, Canakkale2 Department of Psychiatry, Medical School, Canakkale Onsekiz Mart University, Canakkale3 Department of Psychiatry, Adıyaman University Faculty of Medicine, Adıyaman4 Department of Internal Medicine, Çanakkale State Hospital, Çanakkale5 Department of Physical Medicine and Rehabilitation, Medical School, Erzincan University, Erzincan

Evaluation of the temperament and character properties of patients with ankylosing spondylitis

Introduction

Ankylosing spondylitis (AS) is a chronic inflammatory disease, characterized by inflammation of the sacroiliac joints and enthesis regions, which causes a signif-icant decrease in the patient’s quality of life, health status, and ability to work [1]. The disease leads to severe disability in at least one third of the patients [2]. The main complaints of the patients are pain, stiffness, and limited mobility, which sig-nificantly affect their quality of life and their perceptions of the disease [1]. Stud-ies have shown that psychiatric disor-ders frequently accompany the course of this disease [3, 4]. The level of psychiat-ric symptoms among AS patients has al-so been found to be higher than in the general population [5]. The psychiatric symptoms that have been reported most frequently in patients with AS are de-pression and anxiety [4]. It is known that there is an association between the clini-cal course of AS and the patient’s mental status, and psychiatric conditions have been found to be linked to clinical dete-rioration in patients with this disease [6]. The patients’ perceptions of their disease, including their personal views about AS, also play a key role in detecting the ef-fects of AS [7, 8].

Cloninger et al. [9] developed a di-mensional psychobiological model for evaluating the personalities of patients,

by examining two main components of personality: temperament and character. Temperament properties, which can be defined as inborn tendencies to respond automatically, in a unique way, to emo-tional stimuli [10], play an important role for AS patients. Numerous reports have associated temperament properties with dopaminergic, serotoninergic, nor-epinephrinergic, and glutamatergic dys-functions and also with the course of the disease and the response to treatment in patients with nonpsychiatric diseases [9, 11, 12, 13]. Temperament properties are thought to have a 40–60% genetic com-ponent. The contributions of genetic components and environmental compo-nents to character properties are thought to be 10–15% and 30–35%, respectively [9, 11, 14].

Based on these data, this study aims to determine the temperament and charac-ter properties of AS patients according to Cloninger’s psychobiological theory and to examine how these properties are asso-ciated with certain clinical variables.

Materials and methods

This study included 73 AS patients who were diagnosed according to the modi-fied 1984 New York criteria and had vol-untarily accepted to participate in the study.

Sample selection

Before taking part in the study, the sub-jects received information about the re-search and gave their written consent. The patients also provided details about their ages and genders, the duration of their disease, their smoking or drinking histo-ries, any comorbid chronic diseases, the presence of joint stiffness in the morning and its duration, any history of rheumat-ic disease in relatives and any drugs they were taking at that time. To eliminate the effects of psychiatric disorders on the vari-ables, patients who were being treated for a psychiatric disorder or who had a life-time history of psychiatric disorder were excluded. Patients with mental retardation or who had diseases of the brain or central nervous system were also excluded. This study was approved by the Canakkale On-sekiz Mart University Medical School hos-pital ethics committee.

Assessment tools

Visual Analog Scale (VAS). The two ex-tremes of the parameter that is being as-sessed are written at the edges of a 100-mm line, and the patient is asked to draw a line to or put a mark at the place that would indicate his or her status. For pain, “no pain” is written at one edge and “very severe pain” at the other edge. The dis-tance from the point of “no pain” to the

Z Rheumatol 2014 DOI 10.1007/s00393-013-1336-1© Springer-Verlag Berlin Heidelberg 2014

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patient’s mark defines his or her pain lev-el. The mean value of all results has been used for the evaluation. This test has prov-en itself over a long period of time and is widely accepted in the literature. It is reli-able and easy to apply [15].

Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). This is an in-dex used to determine the activity of the disease. The index includes six questions

about the levels of neck, back, lower back and hip pain, fatigue, pain and swelling at peripheral joints, tenderness with pal-pation at several areas of the body and morning stiffness, including its duration. The mean value of the last two questions is calculated together and the mean value of the resulting five items is then obtained. A value ≥4 is accepted as an indication of active disease [16].

Bath ankylosing Spondylitis Functional Index (BASFI). Patients are asked to mark a 10-cm VAS for each of 10 daily activi-ties (such as “can you put on your socks and clothing yourself?” and “can you pick something up from the floor?”) by consid-ering their statuses throughout the previ-ous week [17].

Temperament and Character Invento-ry (TCI). The temperament and charac-ter properties of the patients were evalu-ated using the TCI, which was developed according to Cloninger’s personality the-ory [11]. This is a self-report scale consist-ing of 240 yes–no questions. The tempera-ment dimension includes novelty seeking (NS), harm avoidance (HA), reward de-pendence (RD), and persistence (P). The character dimension includes self direct-edness (S), cooperativeness (C), and self transcendence (ST) [11]. A safety and reli-ability study performed in our country by Samet Kose, Kemal Sayar and Ismail Ak, in 2001, was approved by Cloninger et al. [18]. During the interviews, patients who could not answer the questions or who could only answer them inadequately re-ceived assistance from relatives.

Statistical method

Descriptive statistics were done for each variable. Student’s t test was used to com-pare the parametric variables for detect-ing differences between genders. Pearson and the multiple linear regression analy-sis (method: stepwise) was used to identi-fy the predictors of disease activity in rela-tion to temperament scores, demograph-ics, and clinical variables. The validity of the final regression model was determined by analysis of variance. Statistical evalua-tions were done by using the SPSS pack-age program. A p value <0.05 was accept-ed as statistically significant.

Results

This study included 73 patients who had AS: 25 women (34.2%) and 48 men (65.8%). The mean age of the patients was 42±11.4 years (median 40 years, min–max 19–65 years), the disease duration was 3.8 years (range 0.25–40 years), and 56.2% of the patients had primary level educa-

Tab. 1  Sociodemographic and clinical features of patients according to sex

  Women (n; 25)Mean ± SD/med (min–max)

Men (n; 48)Mean± SD/med (min–max)

p t/z

Age (years) 45±8.6 40.5±12.5 0.12 1.58

BMI (kg/m2) 31.1±6.3 26.5±4.4 0.002 3.26

Disease duration (years)

3 (0.25–40)a 4 (0.25–31)a 0.40 −0.84a

ESR (mm/h) 37.8±16 23.9±14.1 <0.001 3.82

CRP (mg/dl) 0.9±0.6 1.06±0.9 0.42 −0.81

VAS (mm) 55.6±23.6 45.2±29.2 0.13 1.53

BASDAI 4.48±2.03 3.47±2.08 0.51 1.98

BASFI 2.67±2 2.68±2.21 0.98 −0.21BMI body mass index, ESR erythrocyte sedimentation rate, CRP C-reactive protein, VAS Visual Analog Scale, BASDAI Bath Ankylosing Spondylitis Disease Activity Index, BASFI Bath Ankylosing Spondylitis Functional Index. aMedian and z values are given due to non-normal distribution.

Tab. 2  Mean temperament and character scores of patients according to sex

  Women (n; 25)Mean ± SD

Men (n; 48)Mean± SD

p t

Self-transcen-dence (ST)

46.7±4.9 45.6±4.9 0.40 0.85

Cooperativeness (C)

58±4.1 59.1±3.3 0.19 −1.32

Self-directed-ness (S)

62.9±6.1 63.3±6.6 0.81 −0.25

Persistence (P) 11.3±1.4 11.3±1.5 0.89 0.14

Reward depen-dence (RD)

31±2.6 31.5±3 0.42 −0.81

Harm avoidance (HA)

50±4.5 51±4 0.41 −0.83

Novelty seeking (NS)

55.8±4 56±3.6 0.78 −0.28

Tab. 3  Regression model according to Bath Ankylosing Spondylitis Disease Activity Index scores

Model B SD β t p

S −0.098 0.037 −0.300 −2.649 0.01S self-directedness.

Tab. 4  Regression model according to Visual Analog Scale scores

Model B SD β t p

RD −0.245 0.110 −0.256 −2.230 0.029RD reward dependence.

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tion. In all, 54 patients (74%) were using nonsteroidal anti-inflammatory drugs and 19 (26%) were receiving anti-TNF treat-ment. HLA-B27 was determined in 62 pa-tients and 44 (71%) were HLA-B27 pos-itive. The mean erythrocyte sedimenta-tion rate (ESR) was 28.6±16 mm/h (range 0–20 mm/h), C-reactive protein (CRP) was 1±0.8 mg/dl (range 0–0.5 mg/dl), the BASDAI score was 3.8±2.1, and the BAS-FI score was 2.7±2.1. The mean TCI sub-scale scores were self-transcendence (ST): 46±4.9 (min–max 37–57), cooperative-ness (C): 58.7±3.6 (min–max 48–67), self-directedness (S): 63.1±6.4 (min–max 48–78), persistence (P): 11.3±1.5 (min–max 8–15), harm avoidance (HA): 50.5±4.2 (min–max 42–60), reward dependence (RD): 31.2±2.9 (min–max 26–38), and novelty seeking (NS): 56±3.8 (min–max 49–66). A comparison of the sociodemographic and clinical features found that only the body mass index and ESR were signifi-cantly different (. Tab. 1).

We were not able to detect any signif-icant differences through a comparison of temperament and character scores ac-cording to gender (. Tab. 2).

Comparison of the temperament and character properties of the patients ac-cording to their HLA-B27 statuses showed no significant differences, except that ST was higher in patients who were HLA-B27 positive (p=0.049, t=2.02).

Slight negative correlations were de-tected between the BASDAI and S scores (p=0.01, r=−0.30) and between the VAS and RD scores (p=0.03; r=−0.26) in the correlation analyses between the activi-ty scales of the disease and the temper-ament and character properties. How-ever, there was no significant correla-tion between ESR, CRP and tempera-ment and character scores (p>0.05). On the other hand, S scores was significant-ly lower in patients with higher subjec-tive disease activity (BASDAI ≥4) com-pared to patients with lower disease ac-tivity (p=0.027, t=2.25), while there was no difference between groups in terms of objective disease activity parameters such as ESR and CRP.

Regression analysis revealed that the associations between the BASDAI and S (. Tab. 3) and the VAS and RD (. Tab. 4) were statistically significant.

Discussion

Cloninger developed a dimensional psy-chobiological personality model that ex-plains the normal and abnormal varia-

tions in two main dimensions of person-ality: temperament and character [11]. This study used the Turkish version of the TCI, which was translated by Kose et al. [18], for AS patients and examined the as-

Abstract · Zusammenfassung

Z Rheumatol 2014 · [jvn]:[afp]–[alp]   DOI 10.1007/s00393-013-1336-1© Springer-Verlag Berlin Heidelberg 2014

F. Gokmen · K. Altinbas · A. Akbal · M. Celik · Y. Savas · E. Gökmen · H. Reşorlu · A. KaracaEvaluation of the temperament and character properties of patients with ankylosing spondylitis

AbstractPurpose.  The aim of this study was to eval-uate temperament and character of ankylos-ing spondylitis (AS) patients and to examine the association between these specific tem-perament and character properties and clin-ical variables.Patients and methods.  This study involved 73 AS patients. Temperament properties of patients were evaluated using Cloninger’s Temperament and Character Inventory (TCI). Association between clinical variables and specific temperament features were evaluat-ed using correlation and regression analyses.Results.  Forty eight (65.8%) of the study par-ticipants were men and the mean age was 42±11.4 years. There was slight negative cor-relations between self directedness (S) and Bath Ankylosing Spondylitis Disease Activi-ty Index (BASDAI) scores (p=0.01, r=−0.30), and between the Visual Analog Scale (VAS) 

and reward dependence (RD) scores (p=0.03, r=−0.26). Regression analysis showed that correlations between BASDAI and S, and be-tween VAS and RD scores were statistically significant.Conclusion.  Our study showed that the di-mensions temperament and character are related to disease activation, and disease course is more severe in patients who have low scores in these TCI dimensions. Therefore, we suggest that evaluating temperament and character properties of AS patients will help clinicians to predict treatment compli-ance and motivation of patients during dis-ease course.

KeywordsAnkylosing spondylitis · Disease activity · Temperament · Personality · Treatment compliance

Bestimmung der Temperaments- und Charaktereigenschaften von Patienten mit ankylosierender Spondylitis

ZusammenfassungZielsetzung.  Ziel der Studie war es, das Tem-perament und den Charakter von Patient-en mit ankylosierender Spondylitis (AS) zu bestimmen. Zudem sollten die Beziehungen zwischen diesen typischen Temperaments- und Charaktereigenschaften sowie klinischen Variablen untersucht werden.Patienten und Methoden.  In die Stud-ie wurden 73 AS-Patienten eingeschlos-sen. Eigenschaften des Temperaments wur-den mithilfe von Cloningers Temperament and Character Inventory (TCI) bestimmt. Zur Untersuchung der Assoziation zwischen klinischen Variablen und typischen Tempera-mentsmerkmalen wurden Korrelations- und Regressionsanalysen herangezogen.Ergebnisse.  An der Studie nahmen 48 Män-ner teil (65,8%), das Durchschnittsalter lag bei 42±11,4 Jahren. Leicht negative Korrela-tionen bestanden zwischen den Scores der Selbstlenkungsfähigkeit (S) und des Bath Ankylosing Spondylitis Disease Activity In-dex (BASDAI; p=0,01; r=−0,30) sowie zwisch-

en den Punktwerten der visuellen Analog-skala (VAS) und der Belohnungsabhängig-keit (RD; p=0,03; r=−0,26). Regressionsanal-ysen ergaben eine statistische Signifikanz für die Korrelation zwischen BASDAI und S sow-ie VAS und RD.Schlussfolgerung.  Unsere Studie belegt, dass die Dimensionen Temperament und Charakter mit der Krankheitsaktivität in Beziehung stehen. Der Krankheitsverlauf ist bei Patienten mit niedrigen Punktwerten in diesen TCI-Dimensionen schwerer. Da-her schlagen wir vor, die Temperaments- und Charaktereigenschaften von AS-Patienten zu bestimmen, um so die Vorhersage der Thera-piecompliance und Motivation der Patienten im Krankheitsverlauf zu erleichtern.

SchlüsselwörterAnkylosierende Spondylitis · Krankheitsaktivität · Temperament · Persönlichkeit · Therapiecompliance

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sociations between the patients’ tempera-ment and character properties and their evaluations of their disease characteristics. The results of our study indicated nega-tive correlations between S and the BAS-DAI scores and between RD and the VAS scores. Also, the assessments of tempera-ment and character properties according to HLA-B27 positivity revealed a signifi-cant, although only slight, elevation of the ST score in patients who were HLA-B27 positive.

Temperament properties (HA, RD, NS, and P) reflect inborn tendencies to re-spond automatically, in a unique way, to emotional stimuli. These properties may appear during infancy and may be sim-ilar among members of specific cultural groups [19]. Cloninger’s personality mod-el detected that the principle emotions al-ter the levels of perceptual knowledge and shape early learning characteristics, such as a person’s unconscious responses to conditional stimuli [9]. These tempera-ment properties are therefore important for determining an individual’s response in terms of stress and coping mechanisms. RD is associated with an individual’s be-havioral maintenance system and is a he-reditary tendency that manifests in emo-tionality, social binding, and dependence on the approval of others [10, 11, 12, 13, 14]. Individuals with high RD scores are thought to have high thresholds for pain so that they tend to perceive less pain [9, 11]. However, these people express their emotions easily and tend to share their feelings with others.

Ak et al. [20] found high RD scores in male patients with psoriasis and reported that the temperament properties of these patients are characterized by emotional-ity, dependence, and binding. Kose et al. [18] found high RD scores among women in the Turkish population and have sug-gested that this elevation shows that gen-der and cultural variations can affect tem-perament and character properties. Based on this suggestion, the significant nega-tive correlation between the VAS and RD scores in our study may indicate that RD scores negatively correlate with pain ex-pression and with the severity of the dis-ease. In addition, our research supports the notion that people who are reward

dependent are less prone to perceive pain [9, 11].

Character is mainly learned through environment; it can be defined as the rule of execution, which includes rule setting, execution, and judgment, and is sensitive to learning and maturation [9]. In one study that examined character dimen-sions, Ak et al. [20] found higher ST scores in patients with psoriasis than in controls. Self-transcendent individuals are creative, non-selfish, spiritualistic, and idealistic [9, 12, 14], and this property is thought to help psoriasis patients accept the disease and comply with treatment [20]. In our study, ST was significantly but only slightly more positive in patients who were HLA-B27 positive (p=0.049, t=2.02). This property can help patients who are HLA-B27 posi-tive to accept the disease and comply with treatment considering that ST individu-als are creative, idealistic, non-selfish, and spiritualistic [9, 12, 14]. However, it is dif-ficult to explain the possible relation be-tween HLA-B27 and ST scores. Moreover, taking into account the power of p value and relatively low proportion of HLA-B27 positive individuals with AS in our sam-ple, it makes it difficult to generalize our finding. Thus, further prospective follow-up studies comparing ST scores between HLA-B27 positive and negative patients would be helpful to clarify this possible relationship.

The character dimension S involves taking responsibility for a person’s own choices, setting personally significant goals, developing skills and confidence in problem solving, and accepting one-self. Self-directed individuals are autono-mous, responsible, skillful, accepting and dutiful and have goals. Altinoren et al. [21] found low S scores in patients with fibro-myalgia syndrome and Borkowska et al. [22] found low S scores in patients with non-ischemic heart disease, and these au-thors have suggested that this decrease may be related to the duration and sever-ity of the disease. Conrad et al. [23], who found low S scores in patients with chron-ic pain, have suggested that this may be as-sociated with self efficiency and that cog-nitive behavioral therapy may be impor-tant for pain control. Also, in our study the S points decreased with increasing disease activity (p=0.01, r=−0.30).

Since S scores are accepted as being the main component of personality matura-tion, the lower scores in the patients than in the controls is thought to reflect the ef-fects of the disease on personality [20, 21, 22, 23]. This may be due to the duration and severity of the disease and to accom-panying depression because low S scores have been suggested to be a component of the character profile, which is associat-ed with a vulnerability to mood and pain disorders [24]. The negative correlation found in our study between S scores and the severity of the disease suggests that disease severity in these patients may af-fect personality. In addition, we also found lower S scores in patients with higher sub-jective activity independent from objec-tive parameters (ESR and CRP). At the same time, higher subjective disease activ-ity might be concluded as a consequence of the specific character S that is strongly related with taking responsibility for a per-son’s own choices, setting personally sig-nificant goals, developing skills and con-fidence in problem solving, and accept-ing oneself. This finding also could refer to the relationship between S and disease awareness among patients with subjective higher or lower disease activity.

Although our study included AS pa-tients who had no psychiatric diagnosis, the absence of a psychiatric evaluation nevertheless remains a limitation. On the other hand, this could also be interpret-ed as a feature that is specific to patients who have AS. But it is impossible to com-pare our results with those of others be-cause this is the first study that uses TCI in evaluating the temperament and character properties of patients with AS. Although a common temperament and character profile for musculoskeletal diseases has not been established in previous studies, common findings from these studies in-clude increased RD and ST scores, de-creased S scores, and an association be-tween these scores and the severity of the disease [18, 20].

Other limitations to this study, in ad-dition to the absence of any psychiatric evaluation of the patients, include the rel-atively small sample size, the absence of a control group and the use of self-evalua-tion scales. Additionally, relatively lower proportion of HLA-B27 positive patients

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and late onset of disease in our sample comparing with the general literature can make it difficult to generalize our find-ings. It is difficult from this study to deter-mine whether the temperament and char-acter properties of these AS patients are ethiologic or triggering factors. Addition-al comparative studies that include larg-er sample sizes and more patient groups in terms of the ages and genders of pa-tients are required to assess the effects of temperament and character properties on long-term treatment goals.

Nevertheless, our study is the first to evaluate the temperament and character properties of patients who have AS. We found that the RD temperament property and the S character property are both as-sociated with activation of the disease and that the course of the disease is more se-vere in patients who have low RD and S scores. Therefore, we suggest that deter-mining temperament and character prop-erties in AS patients will help clinicians to predict the patients’ compliance in treat-ment and their motivation. Considering the importance of psychosocial support in the prognosis for AS patients, we think that temperament and character proper-ties should be considered when planning a treatment approach for patients who have this disease [20].

Corresponding address

F. GokmenDepartment of Physical Medicine  and Rehabilitation, Medical School,  Canakkale Onsekiz Mart University17110 CanakkaleTurkeyferhatgokmen06@hotmail.com 

Compliance with ethical guidelines

Conflict of interest.  F. Gokmen, K. Altinbas, A. Akbal, M. Celik, Y. Savas, E. Gökmen, H. Reşorlu, and A. Karaca state that there are no conflicts of interest. 

All studies on humans described in the present man-uscript were carried out with the approval of the re-sponsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form).

References

  1.  Ozgül A, Peker F, Taskaynatan MA et al (2006) Ef-fect of Ankylosing spondylitis on health-related quality of life and different aspects of social life in young patients. Clin Rheumatol 25(2):168–174

  2.  Healey EL, Haywood KL, Jordan KP et al (2013) Pa-tients with well-established ankylosing spondylitis show limited deterioration in a ten-year prospec-tive cohort study. Clin Rheumatol 32(1):67–72

  3.  Günaydin R, Göksel Karatepe A, Ceşmeli N et al (2009) Fatigue in patients with ankylosing spondy-litis: relationships with disease-specific variables, depression, and sleep disturbance. Clin Rheumatol 28(1):1045–1051

  4.  Barlow JH, Macey SJ, Struthers GR (1993) Gender, depression and ankylosing spondylitis. Arthritis Care Res 6(1):45–51

  5.  Martindale J, Smith J, Sutton CJ et al (2006) Dis-ease and psychological status in ankylosing spon-dylitis. Rheumatology 45(10):1288–1293

  6.  Eren İ, Şahin M, Cüre E et al (2007) Interactions be-tween psychiatric symptoms and disability and quality of life in ankylosing spondylitis patients. Arch Neuropsychiatry 44(1):1–9

  7.  Murphy H, Dickens C, Creed F et al (1999) Depres-sion, illness perception and coping in rheumatoid arthritis. J Psychosom Res 46(2):155–164

  8.  Baubet T, Ranque B, Taieb O et al (2011) Mood and anxiety disorders in systemic sclerosis patients. Presse Med 40(2):111–119

  9.  Cloninger CR, Svrakic DM, Przybeck TR (1993) A psychobiological model of temperament and character. Arch Gen Psychiatry 50(12):975–990

10.  Von Zerssen D, Akiskal HS (1998) Personality fac-tors in affective disorders: historical developments and current issues with special reference to the concepts of temperament and character. J Affect Disord 51(1):1–5

11.  Cloninger CR, Przybeck TR, Svrakic DM, Wetzel RD (1994) The Temperament and Character Inventory (TCI): a guide to its development and use. Center for Psychobiology of Personality. Department of Psychiatry, Washington University School of Medi-cine

12.  Köse S (2003) A psychobiological model of tem-perament and character (TCI). Yeni Symp 41(2):86–97

13.  Peirson AR, Heuchert JW, Thomala L et al (1999) Relationship between serotonin and the temper-ament and character inventory. Psychiatry Res 89(1):29–37

14.  Cloninger CR (1987) A systematic method for clinical description and classification of person-ality variants. A proposal. Arch Gen Psychiatry 44(2):573–588

15.  Averbuch M, Katzper M (2004) Assesment of visu-al analog versus categorical pain for measurement of osteoarthritis pain. J Clin Pharmacol 44(4):368–372

16.  Garrett S, Jenkinson T, Kennedy LG et al (1994) A new approach to defining disease status in anky-losing spondylitis: the bath ankylosing spondylitis disease activity index. J Rheumatol 21(12):2286–2291

17.  Calin A, Garrett S, Whitelock H et al (1994) A new approach to defining functional ability in ankylos-ing spondylitis: the development of the bath an-kylosing spondylitis functional index. J Rheumatol 21(12):2281–2285

18.  Köse S, Sayar K, Kalelioglu Ü et al (2004) Turkish version of the Temperament and Character Inven-tory (TCI): reliability, validity and factorial struc-ture. Bull Clin Psychopharmacol 14(3):107–131

19.  Sadock BJ, Sadock V (2004) Kaplan & Sadock’s comprehensive textbook of psychiatry. Lippincott Williams & Wilkins, Baltimore

20.  Ak M, Haciomeroglu B, Turan Y et al (2012) Tem-perament and character properties of male psoria-sis patients. J Health Psychol 17(2):774–781

21.  Altunoren Ö, Orhan FÖ, Nacitarhan V et al (2011) Evaluation of depression, temperament and char-acter profiles in female patients with fibromyalgia syndrome. Arch Neuropsychiatry 48(1):31–38

22.  Borkowska A, Pulkowska J, Pulkowski G et al (2007) Association of temperament, character and depressive symptoms with clinical features of the ischaemic heart disease. Wiad Lek 60(5–6):209–214

23.  Conrad R, Schilling G, Bausch C et al (2007) Tem-perament and character personality profiles and personality disorders in chronic pain patients. Pain 133(1–3):197–209

24.  Malmgren-Olsson EB, Bergdahl J (2006) Tempera-ment and character personality dimensions in pa-tients with nonspecific musculoskeletal disorders. Clin J Pain 22(7):625–631

5Zeitschrift für Rheumatologie 2014  |