Mark Ruffalo, the lead author of this paper, is also editor of the Carlat Psychotherapy Report (in full disclosure, a journal I am affiliated with)
Two mood temperaments that are often mistaken for personality disorders
STUDY: Ruffalo ML and Ray AM, Psychodynamic Psychiatry 2026
STUDY TYPE: Review (clinical and psychoanalytic perspective)
FUNDING: Independent
Background
Temperament is the biologically based traits that endure throughout life and govern how we relate and act in the world. Whether we seek out new opportunities or shy away; how emotional and reactive we are; how energetic we are and how much sleep we need.
Those traits resemble mood symptoms, and 40-50% of people with mood disorders have unique affective temperaments. Kraepelin described them as subclinical traits and, common in his manic-depressive patients and in their healthy relatives. Later, Hagop Akiskal formalized their description with the TEMPS-A scale.
Table from The Depression and Bipolar Workbook
A fifth type, the anxious temperament, was added later. It is clinically useful but not as well studied.
Modern psychiatry and psychoanalysis dropped temperament from their diagnostic frameworks, and that gap leaves clinicians blurring cyclothymic temperament with borderline personality disorder, and hyperthymic temperament with narcissistic personality disorder. This review focused on those two distinctions.
Cyclothymic vs Borderline
Cyclothymic temperament causes spontaneous swings between low-grade depression and high energy and confidence. It runs in families with bipolar disorder, and most patients keep a stable identity and stable relationships.
Borderline personality disorder can look similar on the surface, but the mood shifts follow a perceived rejection or abandonment instead of arising on their own. Its core features are identity disturbance, splitting and other primitive defenses, chronic emptiness, and self-injury, and it traces back to relational trauma rather than a family history of mood disorder.
Dr. Aiken’s Take
I agree with those distinctions, and cyclothymic and borderline can also occur together. In her textbook on DBT for borderline, Marsha Linehan wrote that people with borderline have a unique temperament, and that the closest thing she’s found to an accurate description is “cycloid personality.” That was an older term, used in the drafts for DSM-III, which closely resembles cyclothymic temperament.
Akiskal found that 39% of patients with bipolar II had cyclothymia, and the two together predicted a stormier course that resembled borderline, with self-harm and relationship problems. Substance use is another common feature of cyclothymia.
When both are present, lamotrigine, omega-3, and circadian rhythm regulation are my first-line treatments, but we don’t have A-level research to guide this.
Marsha Linehan, founder of Dialectical Behavioral Therapy for Borderline Personality
Hyperthymic vs Narcissism
Hyperthymic temperament brings persistent high energy, a reduced need for sleep, and optimism based on actual accomplishments. It isn’t in DSM-5, and people with it tend to hold steady jobs and relationships.
Narcissistic personality disorder can look the same on the surface: confident, energetic, and successful. But the grandiosity is compensatory, not built on real accomplishments, and self-esteem is fragile underneath it. Relationships cycle through idealization and devaluation, and criticism can trigger rage or collapse.
Dr. Aiken’s Take
When patients have features of both hyperthymic and narcissism, these signs point most toward hyperthymic:
- Decreased need for sleep (4-6 hours/night)
- Family history of bipolar disorder
- Worsening on antidepressants
Age worsens sleep for all of us, however, hyperthymic included. After middle age, they often complain of insomnia and fragmented sleep, needing more.
Also, the third point there is not absolute. In some studies hyperthymic is a risk factor for mood-worsening on antidepressants. In one study, it predicted full recovery on antidepressants. The difference, I suspect, lies in whether they have a family history of bipolar.
That’s me with Hagop Akiskal, at the NCPA conference in Wilmington, NC, 2010
Practice Implications
- Get to know the affective temperaments. They will help you understand the struggles people with mood disorders have outside of their episodes, and make you think twice before diagnosing other disorders that look like them.
- Learn how mood temperaments overlap with ADHD in our Carlat Podcast.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
