Original Paper
Psychopathology 2007;40:2934 Received: February 25, 2005
DOI: 10.1159/000096387
Differences in Temperament, Character
and Psychopathology among Subjects
with Different Patterns of Cannabis Use
Gianfranco Spalletta a, b Pietro Bria c Carlo Caltagirone a, b
a
IRCCS Fondazione Santa Lucia, b Department of Neuroscience, University of Tor Vergata, and
c
Institute of Psychiatry, Catholic University of Sacred Heart, Rome, Italy
Key Words
Cannabis abuse
Character dimensions

Dual diagnosis
Abstract
Background: Patients who use illicit drugs and suffer
from comorbid psychiatric illnesses have worse out-
comes than drug users without a dual diagnosis. For this
reason we aimed at identifying predictors of cannabis
use severity using a multivariate model in which differ-
ent clinical and socio-demographic variables were in-
cluded. Sampling and Methods: We administered the
Temperament and Character Inventory, SCID-P, SCID-II,
the Beck Depression Inventory and the State-Trait Anxi-
ety Inventory. Of the 84 subjects included, 25 were oc-
casional users, 37 were abusers, and 22 were dependent
on cannabis. Results: A stepwise multiple regression
analysis identified increased self-transcendence scores
and state anxiety severity as the only predictors of a in-
creased cannabis use severity (F = 6.635; d.f. = 2, 81; p =
0.0021). In particular, in a further multivariate analysis of
variance, the transpersonal identification issue of self-
transcendence was associated significantly (F = 4.267;
d.f. = 2, 81; p = 0.017) with greater severity of cannabis
use. Conclusions: Character dimension of self-transcen-
dence and symptoms of state anxiety should be taken
2007 S. Karger AG, Basel
02544962/07/04010029$23.50/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
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Accepted after revision: December 29, 2005
Published online: October 19, 2006
into consideration during the assessment procedure of
patients with cannabis use as they may be helpful in the
discrimination of cannabis use severity.
Copyright 2007 S. Karger AG, Basel
Introduction
It is now established that patients who use illicit drugs
and suffer from comorbid psychiatric illnesses have
worse outcomes than drug users without a dual diagno-
sis [1]. In addition, patients with a psychoactive sub-
stance use diagnosis usually experience a progression
from abuse to dependence. The progression is very rap-
id for cocaine and opiate disorders but it also occurs in
cannabis and alcohol use [2, 3]. In this context, genetic
and environmental inuences cannot fully explain can-
nabis use severity and progression towards other illicit
drugs. Indeed, one other important issue is the ease of
access to cannabis already at a young age, which may
favour a reduced perception of the risks connected with
drug abuse as well as a compromised judgment of its
consequences [3].
These data highlight the necessity to use psychometric
instruments in order to measure both clinical and person-
ality characteristics in patients with early cannabis use.
Moreover, an analysis of character dimensions may help
Gianfranco Spalletta, MD
IRCCS Fondazione Santa Lucia, Laboratorio di Neurologia Clinica e Comportamentale
Via Ardeatina, 306
IT00179 Roma (Italia)
Tel. +39 06 5150 1575, Fax +39 06 5150 1388, E-Mail g.spalletta@hsantalucia.it
to discriminate risk factors usually not fully considered
in clinical practice.
From a personality perspective, DSM Axis II diagno-
ses are by denition categorical and many pathological
qualitative traits must be identied at the same time to
diagnose personality disorders. One alternative ap-
proach to dening personality is the dimensional one,
which allows for assessment of individual quantitative/
continuous traits [4]. Among the other dimensional cat-
egorizations, the Cloninger research group [57] in re-
cent years has developed a model of personality in which
4 dimensions of temperament and 3 character dimen-
sions may be identied. Temperament is inheritable,
has an anatomical base, is manifest early in life, stable
and associated with DSM Axis II categories. Character
is socio-environmentally determined, reects individual
maturation and differences in goals and may change
over time [6]. In order to assess temperament and char-
acter traits a questionnaire called Temperament and
Character Inventory (TCI) has been developed [7]. This
permits the following temperament traits to be mea-
sured: (1) novelty seeking, which is an inclination to re-
spond with intense excitement to novel stimuli or cues
for potential rewards, relief or punishment, thereby ac-
tivating/initiating behaviour (controlled by the dopami-
nergic system); (2) harm avoidance, which reects the
efciency of the behavioural inhibition system (con-
trolled by the serotonergic system); (3) reward depen-
dence, which is dened as a tendency to respond inten-
sively to reward signals (controlled by the noradrenergic
system), and (4) persistence, which expresses mainte-
nance of behaviour as a resistance to frustration (no
neurotransmitter has yet been identied). In addition,
the other 3 character dimensions that can be measured
by this scale are: (1) self-directedness, an index of how
people identify themselves as autonomous individuals;
(2) cooperativeness, which identies how people see
themselves as a part of humanity, and (3) self-transcen-
dence (ST), an index of how people identify themselves
as integral parts of the universe. Therefore this inven-
tory may be potentially of great utility in the assessment
of both biological-genetic and socio-environmental per-
sonality characteristics in young patients with a canna-
bis use diagnosis.
In this study we used the psychobiological model of
temperament and character dimensions in order to iden-
tify personality discriminators of cannabis use severity in
young people. Furthermore, we assessed DSM-IV Axis I
and II categorical diagnoses and levels of anxiety and de-
pressive psychiatric dimensions. Considering that the
30 Psychopathology 2007;40:2934
state severity of clinical disorders and psychiatric dimen-
sions, especially depression and anxiety, may impair or
decrease the validity of personality evaluation [8, 9], we
excluded patients with severe clinical disorders.
Methods
Subjects and Sampling Procedure
The sample for this study consisted of 84 young men who had
been consecutively referred to the Rome military hospital because
they had been found to have cannabinoid derivatives in urine dur-
ing a compulsory random screening test.
In the Italian army, a random sample of all draftees is screened
for use of illicit drugs through random urine testing. If found posi-
tive, a subject is referred to the nearest military hospital for a com-
pulsory psychiatric examination and, after about 1 month, the
urine test is repeated. If found positive again, the subject is dis-
missed from army service irrespective of the presence of psychiat-
ric symptoms or syndromes. Dismissal from the service has no legal
consequences; however, the record of illicit drug use may make it
difcult to nd employment in certain types of job.
The sample for this study represented a random sub-sample of
screen-positive draftees referred to the Rome military hospital for
psychiatric examination during a 12-month period (i.e. every day,
only the rst patient who was found positive to cannabinoid de-
rivatives in urine was assessed if the inclusion criteria were met).
In particular, to be included in the sample, a subject had to report
use of cannabis only (i.e. not in association with other drugs), have
a negative urine test for other illicit drugs and give written informed
consent after a complete description of the study prior to the clini-
cal assessment. None of the subjects who met the inclusion criteria
refused to participate in the study. All subjects were interviewed
25 days after their last drug use and between 10.00 and 13.00 h.
None of the subjects had ever received either psychological or psy-
chotropic treatment. Exclusion criteria were major medical illness-
es, severe clinical disorders and severe cognitive impairment.
Diagnostic and Psychometric Assessment
Using the Structured Clinical Interview for DSM-IV, Patient
Version (SCID-P) [10], a trained clinical psychiatrist interviewed
the subjects to assess current Axis I disorders. The Structured Clin-
ical Interview for DSM-IV, Personality Disorders (SCID-II) [11]
was separately used by a second trained psychiatrist to assess per-
sonality disorders. Furthermore, we used the Beck Depression In-
ventory (BDI) [12] and the state form of the State-Trait Anxiety
Inventory (STAI-S) [13] to measure the severity of depressive and
anxiety dimensions.
To measure quantitative personality traits we used the Italian
version of the TCI [7], a dimensional 240-item, 2-point (true/false)
self-report questionnaire. Details of the characteristics of this scale
are provided elsewhere [5].
When conducting the SCID interviews, the psychiatrists were
unaware of both the subjects pattern of cannabis use and their
scores on the BDI, STAI-S and TCI dimensions.
At the end of the interview, a third trained psychiatrist, who
was unaware of the SCID, BDI, STAI-S and TCI results, classied
each subjects pattern of cannabis use into one of the two DSM-IV
Spalletta /Bria /Caltagirone
Table 1. Clinical variables of
84 outpatients with different patterns Characteristics DSM-IV patterns of cannabis use
of cannabis use, mean 8 SD use abuse dependence
(n = 25) (n = 37) (n = 22)

TCI (temperament)
Novelty seeking 18.9685.18 19.7084.86 20.5083.98
Harm avoidance 14.5686.30 13.6286.44 16.2386.56
Reward dependence 13.4483.97 14.5783.55 13.3683.05
Persistence 4.4081.41 4.8181.61 4.2781.64
TCI (character)
Self-directedness 31.2088.58 30.9587.32 26.2785.30
Cooperativeness 26.9686.86 27.0085.43 25.1884.81
Self-Transcendence 10.5285.32 12.3285.44 14.5084.91
BDI 5.7688.39 9.4388.62 11.73811.87
STAI-S 34.48812.27 41.27813.08 44.91812.64
DSM-IV Axis I diagnosis (yes) 2 (8%) 7 (19%) 6 (27%)
DSM-IV Axis II diagnosis (yes) 1 (4%) 1 (3%) 4 (18%)
Any DSM-IV diagnosis (yes) 2 (8%) 8 (22%) 8 (36%)

SD = Standard deviation; TCI = Temperament and Character Inventory; BDI = Beck

Depression Inventory; STAI-S = State-Trait Anxiety Inventory, state form.

categories (using the SCID-P) or into the residual group of recre-
ational use. Thus patients were subdivided into those who were
cannabis dependent, those who were cannabis abusers and those
who used cannabis recreationally but did not meet DSM-IV diag-
nostic criteria for abuse or dependence.
Statistical Analyses
Differences in means of socio-demographic continuous vari-
ables of age and educational level were detected by using univariate
analysis of variance (ANOVA). The predictors of the cannabis use
severity pattern were assessed by using a stepwise multiple regres-
sion analysis, using a forward procedure and an F to enter of 4. In
this model, the dependent variable was the cannabis use severity
pattern (coded as cannabis recreational use = 0, cannabis abuse =
1 and cannabis dependence = 2) and the independent variables
were the temperament and character dimension scores, the STAI-S
and BDI scores, the presence of any Axis I and II diagnoses, as
measured by the SCID-P (coded as no = 0, yes = 1), and age and
educational level.
All tests were two-tailed, and the level of statistical signicance
was dened as an alpha less than 0.05.
teria for cannabis abuse or dependence. Thirty-seven
(age = 19.32 8 0.88; years of education = 8.27 8 1.79)
used the substance episodically but showed evidence of a
maladaptive pattern of use and were assigned to the can-
nabis abuse subgroup, and 22 subjects (age = 20.04 8
2.13; years of education = 9.04 8 2.63) were dependent
on cannabis and assigned to this subgroup. Patients with
different patterns of cannabis use did not differ in age
(F = 1.82; d.f. = 2, 81; p 1 0.15) and educational level
(F = 1.45; d.f. = 2, 81; p 1 0.24).
Subjects with an Axis I diagnosis had adjustment dis-
order (n = 6), dysthymia (n = 4), major depression (n =
1), generalized anxiety disorder (n = 2) and intermittent
explosive disorder (n = 2). Axis II personality disorders
included borderline (n = 2), histrionic (n = 2), dependent
(n = 1) and not otherwise specied (n = 1).
In table 1, TCI, BDI and STAI-S scores as well as pres-
ence of DSM-IV Axis I and II diagnoses are reported.

Predictors of Cannabis Use Severity

Results
Socio-Demographic and Clinical Characteristics
Of the 84 participants, 25 (mean age = 19.72 8
1.34 years 8 SD; mean years of education = 9.28 8 3.08)
used cannabis recreationally and were assigned to the oc-
casional-use subgroup because they did not meet the cri-
Results of the stepwise multiple regression analysis are
shown in table 2. In this model, statistically signicant
predictors of the cannabis use severity pattern were the
ST score of the TCI and the STAI-S score. The resulting
equation was signicant (F = 6.635; d.f. = 2, 81; p =
0.0021) and explained 14.1% (r2) of the overall variance
of the dependent variable. In particular, higher ST and

Cannabis and Personality Psychopathology 2007;40:2934 31

Table 2. Stepwise multiple regression analysis: predictors of can- tially to the above-mentioned results we performed a mul-
nabis use severity in 84 cannabis use subjects tivariate ANOVA (MANOVA) to assess the 3 subscales
of ST simultaneously. A series of follow-up ANOVAs
Variable Step 11 Step 21
were used to individually examine the ST1, ST2 and ST3
STAI-S 0.30 (8.07) 0.26 (6.12) sub-scores in patients with different patterns of cannabis
TCI self-transcendence 0.24 (4.82) 0.23 (4.82) use. In table 3 the results of the MANOVA and ANOVA
Age 0.07 (0.44) 0.03 (0.07) analyses are reported.
Educational level 0.05 (0.21) 0.04 (0.12) Transpersonal identication scores differed signi-
BDI 0.00 (0.00) 0.01 (0.00)
Axis I 0.06 (0.32) 0.07 (0.40) cantly between patients with different patterns of canna-
Axis II 0.13 (1.37) 0.13 (1.43) bis use, spiritual acceptance approached statistical sig-
TCI novelty seeking 0.07 (0.36) 0.05 (0.24) nicance, while self-forgetfulness did not statistically dif-
TCI harm avoidance 0.06 (0.30) 0.15 (0.02) fer between subjects with different patterns of cannabis
TCI reward dependence 0.07 (0.44) 0.02 (0.03) use.
TCI persistence 0.04 (0.14) 0.08 (0.54)
TCI self-directedness 0.11 (1.07) 0.08 (0.48)
TCI cooperation 0.05 (0.18) 0.03 (0.07)
r2 0.090 0.141 Discussion
p 0.0057 0.0021
The most interesting and novel nding of this study is
STAI-S = State-Trait Anxiety Inventory, state form; BDI = Beck
Depression Inventory; TCI = Temperament and Character Inven- the relationship between the ST character dimension of
tory. TCI and cannabis use patterns. Indeed, the higher the ST
Coefcient for variables in equation are bold. score, the more severe was the cannabis use. Further-
1
Standard coefcient, F value in parentheses. more, no difference in temperament dimensions was
found between subjects with different patterns of canna-
bis use.
In the past, a limited number of papers described the
relationship between psychoactive substance use and
Table 3. Self-transcendence sub-scores of 84 outpatients with dif- both DSM categories and TCI dimensions of personality;
ferent patterns of cannabis use (mean 8 SD)
as far as we know, this is the rst study aimed at assessing
TCI self-transcendence DSM-IV patterns of cannabis use this issue in patients who use cannabis only. Thus it is
difcult to compare our data with those of other research-
use abuse dependence
(n = 25) (n = 37) (n = 22)
ers, also because there were no distinctions between sub-
jects with different patterns of psychoactive substance
Transpersonal identication1 3.6082.12 4.1382.21 5.4582.38 use in other studies. In particular, Basiaux et al. [14] iden-
Self-forgetfulness 3.3282.27 3.7882.40 3.8282.36 tied higher novelty seeking and lower self-directedness
Spiritual acceptance2 3.6082.20 4.4082.53 5.2382.04
scores in patients with alcohol dependence compared
SD = Standard deviation; TCI = Temperament and Character with a group of control subjects. Furthermore, Gutierrez
Inventory. et al. [15] indicated how lower self-directedness, lower
MANOVA. Roys greatest root: F = 4.004; d.f. = 3, 80; p = cooperativeness and higher ST distinguished those pa-
0.010. tients with drug dependence and comorbid personality
1
ANOVA. F = 4.267; d.f. = 2, 81; p = 0.017.
2
ANOVA. F = 2.890; d.f. = 2, 81; p = 0.061. disorders from those without personality disorders. These
past ndings indicate the possibility that patients with
more severe patterns of substance use could suffer from
character problems. However, the above-mentioned stud-
ies focused their attention on personality disorders and
state anxiety predicted a greater degree of cannabis use the different patterns of psychoactive substance use were
severity. not assessed.
Considering that the ST dimension of TCI includes Our sample study gave results showing that the great-
issues of transpersonal identication (ST1), self-forgetful- er the tendency to transpersonal identication and prob-
ness (ST2) and spiritual acceptance (ST3), in order to ably to spiritual acceptance issues of ST character, the
clarify which of the ST sub-scores contributed preferen- greater the cannabis use severity. This suggests that men

32 Psychopathology 2007;40:2934 Spalletta /Bria /Caltagirone

who are less realistic in their thinking and more involved
in religious experience and spirituality could be at great-
er risk to develop cannabis dependence. Therefore it is
very probable that a reduced perception of barriers against
the use of illicit drugs and of its consequences, due to
character immaturity among many other factors, may fa-
vour a more severe cannabis use and possibly increase the
risk of progression toward other illicit drugs [3]. This as-
pect should be investigated in future longitudinal studies
that include subjects with early initiation of cannabis
use.
Another interesting result is the difference in state anx-
iety dimension between the three groups of patients with
different patterns of cannabis use. In particular, state anx-
iety was the only variable that differed between the three
groups of cannabis users (no other clinical dimension dif-
fered between these subjects).
These results should only be analysed in the light of
the sample characteristics, i.e. young males with no severe
clinical disorders and selected for exclusive cannabis use.
Therefore the ndings cannot be generalized across the
entire population of cannabis users. Furthermore, in this
cross-sectional study it is impossible to fully ascertain
whether higher anxiety levels are the primary cause of
cannabis dependence or whether they are a secondary ef-
fect of the potential legal consequences of being a heavy
cannabis user (dismissal from the army and problems
with certain types of employment). In addition, heavier
dependence on cannabis might lead to more severe anxi-
ety and facilitate ST experiences. However, such a se-
lected sample is particularly interesting, rstly because
the relationship between dual diagnosis (i.e. psychoactive
substance use plus comorbid psychiatric illnesses) and
worse outcome has been described in males only [1], and
secondly because the assessment of personality has been
described as problematic in patients with severe clinical
disorders [9]. Hence, personality assessment should be
deferred until after an efcacious, symptoms-reducing
treatment [8].
From a mere psychometric point of view, our results
suggest that the power of dimensional variables (i.e. char-
acter measured with the TCI and state anxiety measured
with the STAI-S) in identifying patients with different
degrees of cannabis use severity could be greater than tra-
ditional categorical Axis I and II diagnoses. In a previous
independent sample of patients we found that the preva-
lence of both DSM Axis I and Axis II disorders was sta-
tistically different between patients with different degrees
of cannabis use severity [16]. However, in this former
sample, levels of depression and anxiety dimensions were
Cannabis and Personality
much more severe than in the present study, and the prev-
alence of DSM Axis I and II disorders was almost twice
as high. Thus, if it is possible to suggest the usefulness of
the TCI character dimension of ST in discriminating dif-
ferent personality characteristics of patients with differ-
ent degrees of cannabis use, it must still be conrmed in
patients with severe clinical disorders. Finally, due to the
lack of a control group of subjects without a cannabis use
diagnosis and our relatively small sample of cannabis use
patients, the results of this study should be considered as
preliminary.
Despite the above-mentioned limitations, our results
may be useful to clarify the mechanisms underlying the
patterns of more severe cannabis use (i.e. dependence).
Indeed, an interesting study on psychiatric patients [17]
showed that those subjects with higher dissociative symp-
toms had lower self-directedness and higher ST, similar
to the ndings we described in our subjects with patterns
of more severe cannabis use. The authors hypothesized
that this result was the consequence of environmentally
determined, abusive childhood experiences and traumat-
ic events in general. Thus, and also in the light of the
theory of Marsicano et al. [18] that endocannabinoids
may play a role in neutralizing fear-related memories
(which are socio-environmentally determined, such as
character dimensions of personality, and are probably
linked to the anxiety state), it is possible that patients use
cannabis heavily as a form of self-medication for unpleas-
ant experiences [19]. This interpretation of mechanisms
regulating different patterns of cannabis use needs to be
substantiated in future studies by measuring past and ac-
tual life events in addition to personality characteristics
and state psychopathology in patients with different de-
grees of cannabis dependence.
Psychopathology 2007;40:2934 33
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