Temperament: Some Lessons From Galen the Physician

Patient Expert

As I indicated in an earlier post, I am working on a new book on bipolar. "Temperament" is beginning to emerge as an important theme.

Let's begin with the ancient Greeks, who came up with the idea of the "four humors." Thus, "melancholia" corresponded to black bile from the spleen, "choler" to yellow bile from the gall bladder, "sanguine" to a beating heart nourished by the liver, and finally "phlegmatic."

Good mental health depended on an optimal balance of the humors, which were always in a state of flux owing to the seasons and the movements of the planets and so on. According to Galen the Physician living in the second century, "the mind's inclination follows the body's temperature."

Nowhere are the four temperaments more on display than in Shakespeare. Thus, Guildenstern to Hamlet, vouchsafing a word about the king "in his retirement marvelous distempered " with choler."

These days, we think of temperament as the personality types we are born with, heritable traits that remain fairly constant over our lifetimes. The question, from our perspective, is how do we negotiate our shifting and unpredictable environments when the worlds of illness and personality collide - when "state" meets "trait."

Emil Kraepelin, in his 1921 classic, Manic-Depressive Insanity, saw "colorings of mood" as passing "without sharp boundary into the domain of personal predisposition."   His clinical observations revealed depressive episodes as arising mainly out of a depressive temperament and mania from a manic disposition.

In the 1980s, Hagop Akiskal of UCSD essentially asked what happens when opposites face off, say when depression manifests in someone with a manic temperament. These depressions, Akiskal argues, are going to look a lot different than your classic depressions.

Psychiatry recognizes "mixed states," where elements of depression and mania blend into agitated depressions and dysphoric manias. Recall that last time you experienced road rage, whether you were in a car or not. That sort of describes it.

There are other explanations for mixed states, but clearly Dr Akiskal is on to something.

Temperament is also of critical importance when we feel ourselves cycling into plain old depression and hypomania. Both Kraepelin and Akiskal describe "cyclothymic" as a temperament, one characterized by shifts between dysthymia and hyperthymia.

How does this work? Ask yourself: Are you reasonably comfortable in a state of mild depression? This is an entirely different proposition than asking if you would rather not be depressed, in the first place. Of course you would rather not be depressed. But here you are, depressed. If you can live with that, perhaps this is your default personality setting, or at least part of it.

Let's flip it around. How about when you're feeling up? Is this an expression of your natural exuberance or do you sense a certain disconnect from normal? On the surface, there is nothing to distinguish hyperthymia from hypomania. Inside your head, there may be a world of difference.

We don't have all the answers, but we need to be asking questions. Psychiatry is based on averages, but you are unique. Ask your questions. Know thyself.