An Update on Hyperthymic Temperament

BIPOLAR UPDATE

In 2019, Psychiatric Times published an article reporting that hyperthymic temperament (HT) is on the bipolar spectrum. Since then, we have received many reader communications noting that this diagnosis is often not recognized and hence not treated with medications appropriate for bipolar disorder, with sometimes disastrous consequences.

In reviewing the recent literature on HT, it is easy to find hundreds of articles about it, but almost all of them come from Europe and Asia, where there seems to be much more interest in temperaments and their relationship to other psychopathology and medical pathology than there is in the United States.¹ They think temperaments are very important and are the “substrates of mood disorders.”¹ However, none of these publications report medication trials.

The concept of temperament is a product of German nosological research from a century ago, starting with Emil Kraepelin. In the US, the concept was championed by Hagop Akiskal, MD, and his colleagues. The notion of depressive temperament has been incorporated into the DSM-5-TR nosology in the form of “persistent depressive disorder” (formerly dysthymia). The other pole was called hyperthymia by the Germans. DSM committees have considered adding hyperthymia but have not done so, as its research base is still unconvincing to many. However, it seems that in clinical practice, there are individuals who have chronic low-grade hypomanic symptoms: high energy, need for less sleep than others, chronic optimism, and chronic risk-taking. Such individuals can be prone to major depressive disorder and can become severely suicidal. I continue to encounter these individuals in my bipolar consulting practice at Veterans Affairs Boston Healthcare System.

Akiskal has research criteria for HT that include onset before 21 years of age, habitual sleep of less than 6 hours (even on weekends), excessive use of denial, and traits (described originally by Schneider et al) including being overoptimistic, self-assured, grandiose, overtalkative, warm and people-seeking, uninhibited, promiscuous, and meddlesome.² Neurobiological studies have suggested that these individuals have dopaminergic dysregulation.³

Treatment speculations have focused on what medications to use when individuals with HT experience depressive symptoms. The studies have all been uncontrolled; however, it seems that antidepressants are ineffective for these depressive symptoms and often trigger a mixed state or frank mania at times. Mood stabilizers and medications effective for bipolar depression may be more appropriate for the depressive symptoms in these patients. Usually, their sunny temperament does not require treatment and may, in fact, foster excellent productivity and creativity during much of their lifespan.

A small recent observational study found that patients with bipolar disorder who responded to lithium were more likely to have a HT (OR 1.2).⁴ Other observational data reviewed by Baldessarini et al found that treating depression was more successful in patients with both unipolar and bipolar depression (using clinician-chosen treatment) when HT was present.⁵ However, there continues to be a tremendous need for controlled studies of depression treatment in patients with HT.

In an interesting review, it was determined that Ludwig van Beethoven likely had HT and depression; no discrete episodes of mania could be identified from the available records of his life.⁶

Dr Osser is an associate professor of psychiatry at Harvard Medical School in Boston, Massachusetts; a psychiatrist at the Veterans Affairs (VA) Boston Healthcare System, Brockton Division; and codirector of the VA National Bipolar Disorders TeleHealth Program. He reports no conflicts of interest concerning the subject matter of this article.

References

1. Simonetti A, Luciano M, Sampogna G, et al. Effect of affective temperament on illness characteristics of subjects with bipolar disorder and major depressive disorder. J Affect Disord. 2023;334:227-237.

2. Akiskal HS, Mallya G. Criteria for the “soft” bipolar spectrum: treatment implications. Psychopharmacol Bull. 1987;23(1):68-73.

3. Rihmer Z, Akiskal KK, Rihmer A, Akiskal HS. Current research on affective temperaments. Curr Opin Psychiatry. 2010;23(1):12-18.

4. Janiri D, Simonetti A, Luciano M, et al. Type of cycle, temperament and childhood trauma are associated with lithium response in patients with bipolar disorders. Int J Bipolar Disord. 2024;12(1):10.

5. Baldessarini RJ, Miola A, Tondo L. Affective temperaments: effects on treatment response for major depression. Asian J Psychiatr. 2025;103:104355.

6. Erfurth A. Ludwig van Beethoven-a psychiatric perspective. Wien Med Wochenschr. 2021;171(15-16):381-390.