Unusual Suspect: What Role does Temperament Play in the Development of a Mental Health Disorder?

Our genetic make-up contributes 50% of our particular personality or temperament. This means that, when it comes to eating, mood, anxiety, and even post-traumatic stress disorders, half of the reason that these disorders develop is due to our genetic predisposition.[1]

If 50% of the reason why we have the disorder that we do is due to temperament, is there something we can do about the other 50%?
 
Does temperament affect mental health disorders?

Current research is beginning to show that temperament, the unusual suspect, is playing a major role in the development of psychopathology.[2] Temperament is composed of our thoughts, emotions, physical sensations and, most importantly, our responses to the internal and external world inside and around us.

The Polyvagal Theory does an excellent job of explaining how temperament plays a part in the development of psychopathology. The theory specifies etiological mechanisms through which distinct patterns of psychopathology emerge giving us more insight into temperament and emotional dysregulation — both being related to particular psychopathology development.[3]

Polyvagal theory helps us understand how our neurosensory systems play a huge part in our emotions, thoughts, physical sensations, and responses. We are inherently wired, and our life experiences mold us to respond to the world as either open and safe or dangerous and threatening.
 
Overcontrolled vs undercontrolled temperaments

Dr. Tom Lynch used the Polyvagal theory to develop Radically Open Dialectical Behavior Therapy (RO-DBT) — helping the clinician and patient understand more about one’s temperament and the role it plays in the development of certain psychopathologies.

Dr. Lynch describes temperament as a spectrum, with overcontrolled vs undercontrolled personality types.[4] He uses the metaphor of a rose garden to help explain the difference between the two temperaments. When it comes to overcontrolled (OC) and undercontrolled (UC) temperaments, the OC temperament metaphorically sees the thorns before the roses while the UC temperament may only see the roses and not mind the thorns. All of us tend towards one side of this continuum and, like a bell curve, the majority of us will fall within the window of being flexibly controlled.

Here’s a real-life example: I watch my daughter eat the caramel M&M she received for going potty. She carefully bites off the candy coating and then licks the chocolate. Also, she puts the M&M down from time to time to ensure it lasts. This is the art of delayed gratification at its finest. Child development psychologists find that children with more overcontrolled tendencies have the inherent ability to emotionally regulate impulsively eating the M&M.[5]

If you are more OC, you will want more order, safety through certainty, and have sensitivity to chaos and disorder. This is related to anxiety, OCD, and other disorders related to control, etc.

If you are more UC, you will be drawn to more excitement, intrigue, emotion, possibility, a higher level of emotion and more of an intense response. This is related to impulsiveness, substance abuse, mood lability, bipolar, borderline personality disorder, disorders related to emotional intensity and lability, etc.

As I mentioned above, the way we experience the world around us: our reactions, emotions, thoughts, and physical sensations are impacted by our inherent temperament. One of these qualities is our inherent tendency to be over, under, or flexibly controlled as listed below.[6]

Overcontrolled (OC)

• Get minimal sense of reward from most things, even things one really wants
• Highly focused on details
• Cautious or sensitive to threat and avoid when possible
• Inhibited
• Holds true emotions close to self; more constricted and may express opposite of way one feels
• Can be highly rigid, planned, and perfectionistic
• Behaviors are determined by perceived rules and beliefs about what is right
• Tend to avoid new experiences, sensations or risks
• Want to be appreciated for self-sacrifice, achievements, and hard work

Undercontrolled (UC)

• High sensitivity to reward
• Often don't attend much to smaller details
• Less cautious or sensitive to threat and sometimes disregard threat in service of seeking reward
• Uninhibited
• Emotionally expressive; dramatic
• Less rigid, more spontaneous and impulsive
• Behaviors are often mood dependent
• Actively seek new experiences, sensations and more risk-taking
• Want to be understood

Flexibly controlled 

• Adaptable
• Open to critical feedback
• Reflective
• Willing to be wrong
• Identifying what change may be needed
• Purposeful self-inquiry
• Balance of disinhibition and inhibition
• Discoverer
• Curiosity
• Compassion
• Beginner vs. Master
• Learning stance

In treatment, we ask participants to take a series of self-assessments created by Dr. Lynch to determine their temperament. From there, we begin to design their clinical interventions based on what they have identified as maladaptive behavior or patterns that have caused them pain and suffering.
 
Flexibly controlled

If you are like me, when I first read the descriptions of the overcontrolled vs. undercontrolled temperaments, I wanted to place a value on them and identify one temperament as being better than the other. However, neither one has such a value. Rather, we need both temperaments in the world. And both temperaments must work equally hard to find flexible control.

In order to be flexibly controlled, one must observe and build awareness of both temperaments and how they play a part in one’s behavior and life. Both sides of the spectrum have their pros and cons. We all strive for balance and safety — however, it is challenging to find and to stay there.

Being flexibly controlled is one of the three ingredients to psychological health, as listed below:

1. Receptivity & Openness — to new experience and disconfirming feedback in order to learn
2. Flexible-Control — in order to adapt to changing environmental conditions
3. Intimacy & Connectedness with at least one other person — species survival depends on our ability to form long-lasting bonds and work together in tribes or groups[7]
 
Psychological health is about taking chances, taking in feedback, and adapting to the ever-changing environment and relationships around us. It was once believed that we needed to change our thoughts, emotions, and physical sensations. Now we know that is not effective or possible. We cannot control the thoughts, emotions, and physical sensations that arise in our mind and body. Rather the only control we have is over our response to our emotions, thoughts, and physical sensations.
 
The more we understand our temperament, the more we can take control of the other 50%. A diagnosis is a beginning to understand so much more about who we are and our make-up, and what we can do about it.
 
Join me in San Francisco!

During my talk at our 5 CME/CE San Francisco Professional Symposium: New Treatment Strategies for Complex Cases on September 20, 2019, I will talk more in-depth about temperament and how it relates to the development of mood, anxiety, traumatic stress, and eating disorders. Join us in person or via livestream.

Register for the event here.

I hope to see you there!
 
Lara Schuster Effland, LICSW is Regional Managing Director of Clinical Operations, West Coast for Eating Recovery Center and Pathlight Behavioral Health Centers. A licensed clinical social worker, Ms. Effland has been working in the field of eating, mood, anxiety, and trauma-related disorders for over 13 years in multiple levels of care throughout the country. Ms. Effland received her Bachelor’s degree in Psychology from Oberlin College and her Master’s degree in Social Work from Loyola University of Chicago with a concentration in clinical practice. Her training and expertise focus primarily on mindfulness and evidence-based behavioral interventions, such as Dialectical Behavior Therapy, Cognitive Behavioral Therapy, Prolonged Exposure Therapy, and trauma treatments.
 
Ms. Effland joined the Chicago, Pathlight Behavioral Team in 2006 as a DBT therapist. In 2009, Pathlight’s founder Dr. Susan McClanahan and Ms. Effland developed Pathlight’s mood and anxiety program, which Ms. Effland has directed and led since. Ms. Effland became the Executive Clinical Director of Eating Recovery Center’s Washington site in March of 2017. Her experience in co-occurring disorders compliments the exemplary eating disorders care at Eating Recovery Center of Washington. Ms. Effland regularly speaks and trains nationally on the topic of eating, mood, anxiety, and traumatic stress disorders.