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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 15-26

Differential profile of three overlap psychiatric diagnoses using temperament and character model: A systematic review and meta-analysis of avoidant personality disorder, schizoid personality disorder, and social anxiety disorder


1 Department of Psychology, University of Kurdistan, Sanandaj, Iran
2 Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
3 Liver and Digestive Research Center, Sanandaj, Iran
4 Neurosciences Research Center, Sanandaj, Iran
5 Department of Psychiatry, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
6 Student Research Committee, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran

Date of Submission09-Dec-2021
Date of Decision20-Jan-2022
Date of Acceptance30-Jan-2022
Date of Web Publication29-Apr-2022

Correspondence Address:
Dr. Saeid Komasi
Neurosciences Research Center, Kurdistan University of Medical Sciences, Pasdaran Boulevard, Sanandaj
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_148_21

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  Abstract 


Some psychiatric disorders are mostly overlapping and measures for facilitating differential profiles play a key role in the identification of a disease, course, prognosis, and management. This systematic review and meta-analysis aimed to (i) explore the association between the components of temperament and character model and three overlap psychiatric diagnoses including avoidant personality disorder (APD), schizoid personality disorder (SPD), and social anxiety disorder (SAD) and (ii) provide differential profiles for each of these disorders. The literature search was performed on 7 international scientific databases for all articles published in English, January 1990-June 2019. The pooled effect sizes were obtained using the correlation coefficients or the standardized mean differences between cases with SAD and healthy controls by the random-effects method. Fifteen correlational studies for APD and SPD and eight case–control studies for SAD met the criteria for entering meta-analysis. All three disorders were positively associated with harm avoidance (HA) and negatively associated with novelty seeking (NS), self-directedness (SD), and cooperativeness. APD and SPD were also negatively associated with reward dependence (RD). The differential profiles are as follows: NS (APD < SAD), HA (APD > SPD, SAD), RD (SPD < APD < SAD), SD (APD < SPD, SAD), cooperativeness (APD, SPD < SAD), and self-transcendence (ST: APD > SPD, SAD). It seems that HA, SD, and cooperativeness are the common core of these three diagnostic categories. More extreme tendencies in NS and RD, along with ST with a lower possibility, are the main traits in the differential profiles.

Keywords: Character, meta-analysis, personality disorder, social anxiety disorder, systematic review, temperament


How to cite this article:
Hemmati A, Rezaei F, Rahmani K, Shams-Alizadeh N, Davarinejad O, Shirzadi M, Komasi S. Differential profile of three overlap psychiatric diagnoses using temperament and character model: A systematic review and meta-analysis of avoidant personality disorder, schizoid personality disorder, and social anxiety disorder. Ann Indian Psychiatry 2022;6:15-26

How to cite this URL:
Hemmati A, Rezaei F, Rahmani K, Shams-Alizadeh N, Davarinejad O, Shirzadi M, Komasi S. Differential profile of three overlap psychiatric diagnoses using temperament and character model: A systematic review and meta-analysis of avoidant personality disorder, schizoid personality disorder, and social anxiety disorder. Ann Indian Psychiatry [serial online] 2022 [cited 2022 May 22];6:15-26. Available from: https://www.anip.co.in/text.asp?2022/6/1/15/344422




  Introduction Top


Avoidant personality disorder (APD), which has been described as extensive avoidance of social interaction driven by fears of rejection and feelings of personal inadequacy,[1] is closely related to and partially overlapped with social phobia or social anxiety disorder (SAD). For this reason, research and treatment in this field have always faced many challenges.[2],[3] The predominant paradigm endorses the “severity continuum hypothesis,” in which APD is regarded fundamentally as a severe version of SAD.[3],[4] In fact, there is an ongoing debate as to whether APD and SAD can be classified as separate and distinct disorders or whether these diagnoses rather reflect different degrees of severity of social anxiety.[2] Considering 22%–89% co-occurrence and comorbidity between these two disorders,[5],[6],[7] some studies proposed that both APD and SAD should be categorized together so that APD is only the more severe form of the disorder.[5],[8] However, the discontinuity approach, which supports retaining APD as a distinct diagnostic category, has been highlighted.[3] In support of this perspective, the results of a recent study based on the alternative model for personality disorders (AMPD) showed that APD compared with SAD only in the antagonism domain showed greater impairment. However, pathological traits of negative affectivity, especially anxiousness, were higher in the SAD.[9] AMPD is a flexible and practical framework and an innovative system that provides a simultaneous psychiatric classification and psychological assessment of personality disorders through combining major paradigms of personality assessment.[10] Furthermore, in the Hierarchical Taxonomy of Psychopathology (HiTOP), APD belongs to the detachment spectra, whereas SAD is located in the internalizing spectra.[11] HiTOP is a dimensional classification system of psychopathology that covers a wide range of psychiatric problems and tries to address the limitations of traditional taxonomies.[11]

Another challenging disorder with a similar feature is schizoid personality disorder (SPD), which is described as a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings.[1] The patients with SPD, as one of the most under-studied cases and a poorly understood disorder, are characterized by emotional aloofness and detachment from society, coldness, apathy, preferring solitude, and lack of interaction with others because they enjoy a solitary lifestyle.[12],[13] Even though AMPD has not presented SPD as a diagnostic class,[10] HiTOP introduced it as a subset of the detachment and/or thought disorder spectra.[11]

Although several comparative studies and literature reviews pointed to etiological and clinical differences between APD, SPD, and SAD,[3],[8],[14],[15] the relationship between APD and these disorders is probably more complex than previously assumed.[4],[9] Several environmental, constitutional, and temperamental factors may play a role in the etiology of these disorders.[3],[4],[16] A vulnerable temperament combined with early environmental risk factors is suggested etiological factors in the development of these disorders.[4] For example, a large study on female twins found that APD and SAD were influenced by the same genetic factors.[17] Although, the validity of these findings depends on further studies on psychobiological models of personality. The temperaments and character model raised by Cloninger[18] is one of these models that have been of interest to researchers over the past three decades. Temperament traits are included novelty seeking (NS: a trait associated with exploratory activity in response to novel stimulation, impulsive decision making, and avoidance of frustration), harm avoidance (HA: a tendency to excessive worrying, shyness, pessimism, and being fearful and easily fatigued), reward-dependence (RD: a tendency to verbal signals of social support and approval), and persistence (Ps: a tendency to perseverance despite fatigue or frustration). Character traits that are less influenced by genetics and environment play a greater role in their development include self-directedness (SD: the ability to regulate and adapt behavior toward personal goals and values), cooperativeness (Co: the degree of general agreement in interpersonal relationships), and self-transcendence (ST: the expansion of personal boundaries, including spiritual ideas).[18],[19] Numerous studies have examined the relationship between components of temperament and character model and symptoms of personality disorders and SAD.[20],[21],[22],[23],[24],[25],[26] However, the reported results were largely contradictory and inconsistent. Thus, to integrate the findings of previous studies and to achieve a comprehensive coherent conclusion, the present meta-analysis was performed for two purposes: (i) explore the association between the components of temperament and character model and three overlap psychiatric diagnoses including APD, SPD, and SAD and (ii) provide differential profiles for each of these disorders.


  Materials and Methods Top


The present study was registered in Kurdistan University of Medical Sciences (MUK-98724) and received a code of ethics from the Research Ethics Committee (IR.MUK.REC.1398.169). The procedure of the present systematic review and meta-analysis included sources and databases, search strategies, quality assessment of studies, and data extraction based on the instructions for the PRISMA checklist.[27]

Source and databases

The review population included all scientific papers published in English from January 1990 to June 2019. The systematic searches were done in various databases including PubMed (Medline), Scopus, Web of Science, Cochrane, ProQuest, PsycNET, and EBSCO. An initial search of these databases and the Google Scholar context identified 5281 records. Two records were also identified by a manual search of references. After excluding the 1886 duplicate records, inclusion criteria were screened for 3397 identified records [Figure 1].
Figure 1: A flow diagram of the study selection process based on PRISMA

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Search strategies and criteria for selecting study

In the first step, the keywords required for the search process were determined by two members of the research team (AZ and SK). The keywords were chosen based on previous systematic reviews and the literature related to the field of the study. The searches in the title/abstract were carried out using the keywords list included (”Temperament” OR ”TCI” OR ”TCI-R” OR ”TPQ” OR ”novelty seeking” OR ”harm avoidance”) (AND) (”personality disorder” OR ”schizoid personality disorder” OR ”avoidant personality disorder” OR ”social phobia” OR ”social anxiety disorder”). Only English-language original papers published in academic journals, studies related to adults 18 years and older, and those studies that used the TCI, TCI-R, or TPQ to measure temperament or character traits were entered into the systematic review. Mutually, publications outside of the above-mentioned period, interventional studies and other studies with irrelevant design, qualitative reports, dissertations/unpublished papers, conference abstracts, studies that used unstructured interviews and nonstandard instruments for assessing disorders, and low-quality reports based on STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) were excluded. Finally, 15 correlational studies for APD and SPD and 8 case–control studies for SAD met the criteria for entering meta-analysis. Details of the study selection process can be seen in [Figure 1].

Assessment of the quality of studies

The quality of the identified studies was assessed using the 21-item checklist of STROBE [Supplementary 1]. The checklist is used to evaluate the quality of cross-sectional, case–control, and survey studies.[28] The qualitative evaluation process of the papers was separately conducted by two members of the research team (KR and SK), and in case of disagreement between them, the dissonance was resolved through discussion between the three people (FR). According to the present objectives, studies with a cut-off point of seven or less were excluded [Supplementary 2].



Data extraction

A table was designed to record extracted data in the form of a regular categorization for simple understanding. After applying inclusion and exclusion criteria, the data from each study were entered into the registration form. The process of data synthesis included tabulation, detailed descriptions of the findings of each study, and the organization of studies based on authors, year and region, samples, sample size, age range/mean (standard deviation) of the participants, design, statistics, measurement tools and relevant variables, findings (correlation coefficients or the std. means difference), and limitations.

Statistical analysis

Several meta-analyses were performed to calculate the pooled effect size of the correlation coefficients between each of the temperament and character traits (NS, HA, RD, Ps, SD, Co, and ST) and APD/SPD. Studies were combined based on sample sizes and correlation coefficients between variables. The unit of analysis was an individual study and effect sizes in these meta-analyses were obtained by the Fisher z-Transformation of correlation coefficients. Estimates of the correlation coefficients in individual studies were graphically presented for each study based on the temperament and character traits in the pooled forest plots. Furthermore, several meta-analyses were performed separately to calculate the standardized mean difference of the temperament and character traits between cases with SAD and healthy controls. The studies were combined based on sample size, mean, and standard deviation of the variables in the cases and healthy controls. Pooled effects sizes for group differences (cases with SAD vs. controls) are presented with 95% confidence intervals (CI) using a pooled forest plot. Cohen's d values were used for measuring the effect size. Differences between cases and controls were compared using the standard z score.

Due to heterogeneity (I2 > 50% in 96% of the studies, except for disorder APD and Ps), pooled estimates of the standardized mean difference and correlation coefficients were calculated for the temperament and character traits assessed by TCI/TPQ and all disorders using the random-effects method.[29] We studied the heterogeneity of the study samples using the I2 statistics for a 95% CI. A P < 0.05 for I2 higher than 50% was considered a significant heterogeneity. The resulting pooled z-transformed correlation coefficients were back-transformed (z to r transformation) to the level of original coefficients for easier interpretation of the results. Egger's test was used to detect possible publication bias. Because of the lack of coverage of some of the TCI/TPQ subscales in all studies, the number of studies entered into the meta-analysis related to each of the TCI subscales is not equal [Figure 2]. All hypotheses were tested at the level of <0.05 and performed using the Comprehensive Meta-Analysis (CMA.2) software. Finally, effect sizes (correlation coefficients obtained for personality disorders and the standardized mean difference obtained from case–control studies of SAD) were transformed into the standard z score. Thus, all disorders were compared to the temperament and character traits by the standard z scores [Figure 3].
Figure 2: The pooled forest plot for TCI subscales contains a heterogeneous number of studies for each of the temperaments and character traits. Statistically significant correlations between TCI and avoidant/schizoid personality disorders: APD-NS (P = 0.002), HA (P < 0.001), RD (P = 0.002), SD (P < 0.001), Co (P < 0.001); SPD-NS (P = 0.010), HA (P < 0.001), RD (P < 0.001), SD (P < 0.001), Co (P < 0.001). Difference between cases with SAD and healthy controls in the TCI subscales: NS (P = 0.017), HA (P < 0.001), SD (P < 0.001), Co (P = 0.003). Abbreviation: Co: Cooperativeness; HA: Harm avoidance; NS: Novelty seeking; Ps: Persistence; RD: Reward dependence; SD: Self-directedness; ST: Self-transcendence; TCI: Temperament and character inventory

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Figure 3: Differences between APD, SPD, and SAD in temperament/character components using compare (i) the standard z score and (II) the standard z scores >3. Abbreviation: APD: Avoidant Personality Disorder; Co: Cooperativeness, HA: Harm avoidance, NS: novelty seeking, Ps: Persistence, RD: Reward dependence, SAD: Social anxiety disorder, SD: Self-directedness, SPD: Schizoid personality disorder, ST: Self-transcendence

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  Results Top


Studies included in the systematic review

A primary search yielded 5281 papers (PubMed = 247, Scopus = 2968, Web of Science = 187, Cochrane = 141, ProQuest = 1737, EBSCO = 1, PsycNET = 0). Two papers were also found through a manual search for author and reference. Eventually, 33 and 23 papers were included to the final systematic review and meta-analysis, respectively. Eight studies that had samples with SAD compared with the healthy controls and 15 studies that reviewed the relationship between APD/SPD and temperament and character traits were entered into the meta-analysis. These studies were conducted in the USA (n = 12), New Zealand (n = 3), Sweden (n = 3), Italy (n = 2), Netherland (n = 2), Spain (n = 1), France (n = 2), Finland (n = 2), UK (n = 1), Germany (n = 1), Turkey (n = 1), Canada (n = 1), South Korea (n = 1), and South African (n = 1). The results of the quality evaluation of articles using the STROBE checklist can be seen in [Supplementary 2]. The quality of studies ranged from 9 to 19 and the quality of nearly 88% of the articles was medium and higher. The summary of the methods and results of the studies is presented in [Table 1].
Table 1: Data extraction of temperament and character traits related to APD, SPD, and SAD (in alphabetical order)

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Correlations between temperament and character traits and schizoid personality disorder/avoidant personality disorder

[Figure 2] (Parts A and B) presents correlations between temperament traits and SPD/APD. The effect sizes in two pooled forest plots with 95% CI, the z test value and its statistical significance are presented for each disorder. As can be seen, there is a significant relationship between SPD and NS (z = −2.580, P = 0.010), HA (z = 5.024, P < 0.001), RD (z = −6.801, P < 0.001), SD (z = −4.024, P < 0.001), and Co (z = −4.052, P < 0.001). Although, there is not a significant relationship between SPD and Ps (z = −0.364, P = 0.716) and ST (z = 0.346, P = 0.730). Furthermore, relationships between APD and NS (z = −3.125, P = 0.002), HA (z = 9.189, P < 0.001), RD (z = −3.136, P = 0.002), SD (z = −5.929, P < 0.001), and Co (z = −4.363, P < 0.001) were significant. Although, there is not a significant relationship between APD and Ps (z = −0.868, P = 0.385) and ST (z = 1.842, P = 0.066). The publication bias was not seen in the relationship between any of the variables, exception for APD-HA, and Ps (P > 0.05 for Egger's statistic).

Differences between cases with social anxiety disorder and controls in temperament and character traits

[Figure 2] (Part C) presents the standardized mean difference between cases and controls in temperament and character traits. The effect sizes in a pooled forest plot with 95% CI, the z test value, and its statistical significance are presented for each subscale. As can be seen, there is a significant difference between cases and controls in NS (z = −2.388, P = 0.017), HA (z = 7.695, P < 0.001), SD (z = −4.015, P < 0.001), Co (z = −2.927, P = 0.003). Although, there was no difference between the two groups in RD (z = −1.530, P = 0.126), Ps (z = −0.237, P = 0.813), and ST (z = −0.522, P = 0.602). The publication bias was not seen in the difference between any of the variables, exception for NS (P > 0.05 for Egger statistic).

Differential profiles of avoidant personality disorder, schizoid personality disorder, and social anxiety disorder by temperament and character traits

[Figure 3] (Part A) presents the significant differences between APD, SPD, and SAD in temperament and character traits using compare the standard z scores. The figure results show that the three diagnostic categories are different in NS (APD < SAD, P = 0.033), HA (APD > SAD, P < 0.0005; APD > SPD, P < 0.0005), RD (SPD < APD, P < 0.0005; SPD < SAD, P < 0.0005; APD < SAD; P = 0.016), SD (APD < SAD, P < 0.0005; APD < SPD, P < 0.0005), Co (APD < SAD, P < 0.0005; SPD < SAD, P = 0.001), and ST (APD > SAD, P = 0.013; APD > SPD, P = 0.032). [Figure 3] (Part B) also show the differential profile of APD, SPD, and SAD by the standard z scores three and higher in temperament and character traits.


  Discussion Top


This systematic review and meta-analysis were done to explore the association between the components of temperament and character model and three overlap psychiatric diagnoses including APD, SPD, and SAD and to provide differential profiles related to each of these disorders. The present findings showed that all three mental disorders are positively associated with HA and negatively associated with NS, SD, and cooperativeness. APD and SPD are also negatively associated with reward dependence (RD). Another finding indicated the differential profiles of these three diagnostic categories. These findings will be discussed in more detail below.

Temperament traits

The results of the present study confirmed a positive relationship between HA and both personality disorders. The HA also was significantly higher in patients with SAD than healthy controls. Thus, HA is probably the main component in all three diagnosis categories. It has been argued that HA represents the anxiety/inhibition mechanisms characteristic of all the Clusters A and C disorders such as SPD and APD.[22] HA is forcefully affected by GABAergic activity.[43] GABA neurotransmitter is one of the main factors effective in the modulation of anxiety responses; so that dysfunction of this neurotransmitter is essentially effective in increasing fear and anxiety related to personality and anxiety disorders such as SAD.[56] Besides, HA has a similar function to neuroticism in the five-factor model.[57] Neuroticism also is related to APD, SPD, and SAD.[58],[59],[60]

Our results also showed that there is a negative relationship between NS and RD with both personality disorders. Patients with SAD although showed a lower NS than healthy controls; their RD score was not different from the control group. NS consistently tends to show lower orderliness, intolerance to change and insensitivity to incentives in some Clusters A and C disorders such as SPD and APD.[22] Unlike HA that is related to serotonin, NS is caused by dopamine. According to Cloninger,[19] NS correlates positively with the expression of the dopamine transporter responsible for presynaptic reuptake. Higher levels of NS are therefore linked to reduced DA release from presynaptic neurons and compensatory increased sensitivity of postsynaptic striatal dopaminergic receptors.[53] This may explain the lower NS in these disorders, especially SAD.

Regarding RD can be mentioned the extraversion component in the Five-Factor Model. The same function of these two components indicated an intense tendency toward introversion, lack of sensitivity to social reward, and detachment in both personality disorders.[61],[62] RD also reflects two extreme dimensions included emotional hardness and weak affiliation mechanisms in Cluster A disorders.[22]

Character traits

The results of the present meta-analysis indicated that character traits are severely and homogeneously related to all three disorders' severity. Our results were confirmed a negative relationship between SD and Co with both personality disorders. Furthermore, SD and Co were significantly lower in patients with SAD than healthy controls. Hence, character traits, especially SD and Co, are disrupted functions of all three disorders. Given the positive relationship between Co and RD,[22],[35] poorly Co is fully expected in all three disorders, especially APD and SPD. However, the lower level of SD reflects an inability to set long-term goals, poor responsibility, and frequent uses of immature defenses.[36] Immature SD is a core feature for the presence and severity of all PDs regardless of subtype.[36] Fassino et al.[63] referred to the SD along with HA as the personality core of mental illness such as SAD.

Differential profiles by temperaments and character traits

Previous reports[57],[63] pointed to the TCI/TPQ that can be used as a screening or differential diagnosis tool for many psychiatric disorders symptoms. According to the current study finding, the HA score in APD is significantly higher than SPD and SAD. Furthermore, the NS and RD scores in APD are significantly lower than SAD. Mutually, their RD is significantly higher than SPD. These findings indicated that probably APD and SAD, not SPD, are on a continuum. That is, APD and SAD may both be a single disorder with a more severe disturbance in APD. The finding is coordinated with the “severity continuum hypothesis” for APD and SAD.[3],[4] However, the role of RD in separating these two disorders cannot be ignored. Despite the lower RD in APD, our results showed that patients with SAD compared with healthy controls are not disturbed in this component. The inverse relationship of ST with either of these two disorders also violates the “severity continuum hypothesis.”

It can be said with more certainty that SPD and APD are not on a continuum. The key temperament in separating these two disorders is the RD. Although more extreme tendencies of three temperaments (NS, HA, and Ps) and all three characters are on a continuum and more severe in APD, the level of RD in SPD is significantly lower. According to Cloninger et al.,[64] RD is characterized by social attachment and approach to rewards based on a different pattern of activation of dopaminergic neurons in the nucleus accumbens and substantia nigra. Lower RD likely is due to a decreased prevalence of some dopamine polymorphisms.[65] Derangements in mesolimbic dopaminergic pathways and their terminal fields such as the striatum, amygdala, and prefrontal cortex may be effective in anhedonia.[66] Social anhedonia is the most unique correlate of schizoid features. Although, higher internalized shame and the need to belong are the main correlates of APD features.[3]

Regarding the characters, we found that the SD standard score in APD is significantly lower than SAD and SPD, contrary to the ST score that is higher. As previous studies have pointed out,[36],[63] the SD may be the core character of disrupted functions. On the other hand, the Co in both APD and SPD is significantly lower than SAD. Thus, people with APD or SPD compared with patients with SAD report more problems in interpersonal relationships and tend to more severe isolation and detachment.[11] Hence, if the characters are on a continuum, the severity of the dysfunction is higher in APD, SPD, and SAD, respectively.

Methodological considerations and limitations

The present study offers an essential step in identifying psychobiological factors of Cloninger's theory in the field of APD, SPD, and SAD. However, there were also some limitations. Due to a few numbers of case–control studies in the field of personality disorders, the present meta-analysis was performed on the correlation scores. Although all effect sizes obtained from correlational and case–control studies were converted to standard z score, the difference in the studies design under review in the present meta-analysis may make it difficult to compare the effect sizes. In the present study, we compared z standard scores for differential profiles. Of course, calculating effect sizes obtained from studies that originally compare the personality traits between these diagnosis categories are more valid. Another limitation was related to psychiatric comorbidity conditions with the disorders under consideration. These diagnosis categories are not pure and are usually associated with other mental disorders at the same time.[22],[31] In the present meta-analysis, psychiatric comorbidities with the disorders under consideration were not excluded from the analysis. Furthermore, the correlational studies that were entered into the meta-analysis were simultaneously contained the clinical and general populations. Unlike case–control studies that focus on patients with an established APD or SPD, correlation studies examine only the relationship between personality traits and the severity of symptoms. Although these studies were used dimensional instruments (without a cut-off point) for assessing personality and psychiatric disorders highlighted in recent studies,[11],[67],[68],[69] the selection of case–control studies containing clinical patients and healthy controls may be functional.


  Conclusions Top


The current systematic search shows that to date, very limited studies have examined the relationship between the temperament and character model assessed by TCI or TPQ and three diagnosis categories included APD, SPD, and SAD. Although SAD was mainly evaluated in the case–control studies, studies related to the APD and SPD were mostly focused on the correlation between personality traits and the severity of symptoms. In general, the results of the present meta-analysis confirmed a relationship between some temperament and character traits and APD/SPD (NS, HA, RD, SD, and Co), and SAD (NS, HA, SD, and Co). It seems that HA, SD, and Co are the common core of these three diagnostic categories. More extreme tendencies in NS and RD, along with ST with a lower possibility, are the main traits in the differential profiles.

In comparison to the traditional/current categorical criteria of the DSM that is not capable of biogenetic classification and ignores the biological basis of these disorders,[36] the temperament and character model is a relatively more practical biological approach in separating psychiatric disorders included APD, SPD, and SAD. Despite the traits assessed by TCI or TPQ does not entirely serve to perform differential profiles of DSM categories, both the TCI/TPQ and the DSM should currently be considered simply as alternative ways of measuring individual differences.[22]

Although there was publication bias for some personality traits in the studies related to the APD and SAD and low evidence levels were seen in most studies included in the review, large effect sizes were obtained in the meta-analysis. Small sample size and nonrandomized sampling were among the main limitations of the studies included in the meta-analysis. Another challenge was the heterogeneity of participants in correlation studies that examine only the severity of symptoms in a clinical (with or without APD/APD) or nonclinical sample. Finally, although this psychobiological model is relatively effective in the differential profile of APD from two other disorders, a comparison between standard scores in the present study is not reliable enough. Therefore, the future meta-analysis should be focused on case–control studies related to the APD/SPD and the studies that directly compare personality traits between these three diagnostic categories.

Acknowledgments

This article is part of a PhD. thesis of Mr. Saeid Komasi entitled “review and reconsideration of the Hierarchical Taxonomy of Psychopathology (HiTOP) model with an emphasis on psychobiological models in the explanation of somatoform disorders”, financial support and sponsored by the Neurosciences Research Center and the Vice-Chancellor for Research and Technology of Kurdistan University of Medical Sciences, Sanandaj, Iran (ID: MUK-98724).

Financial support and sponsorship

The project was funded by the Kurdistan University of Medical Sciences, Sanandaj, Iran (ID: 98724).

Conflicts of interest

There are no conflicts of interest.



 
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