ankylosing spondylitis ( as ) is a chronic , progressive disease , manifesting with 
 inflammation of the sacroiliac joints and entheses .
this disease may lead to structural and 
 functional disorders1 and may be a 
 significant cause of sleep disorders and reduced quality of life and ability to work2 , 3 , 
 with consequent negative effects on family and social relationships4 , 5 .
the prevalence of 
 psychiatric symptoms has been found to be higher in as patients than in the general 
 population ; the most common psychological symptoms are depression and anxiety6 .
the concept of temperament is related throughout the lifetime 
 of a relatively stable individual to the emotions , cognitive functions , and behaviors 
 experienced in the home at a young age7 .
akiskal , who developed the modern concept of affective temperament , suggested that 
 affective temperament had the potential risk of behavioral disorder8 .
five dominant affective temperaments have been defined : 
 depressive , hyperthymic , cyclothymic , irritable , and anxious .
depression and anxiety may be 
 subtypes of temperament or may develop as comorbidities of as disease . in recent years , the 
 relationship between chronic auto - inflammatory and auto - immune diseases and the temperament 
 of patients has attracted the attention of researchers9,10,11,12 .
the psychiatric status 
 of the patient can affect the disease process , prognosis and even treatment results13 .
therefore , the investigation and 
 treatment of affective temperament in as patients may not only reduce patient concerns and 
 problems , but may also provide alternative approaches to treatment and should be taken into 
 consideration when planning treatment for these patients14 . to date , there has been no controlled study evaluating affective 
 temperament in as patients and examining the relationship between existing depression and/or 
 anxiety and dominant affective temperament . in this study
, we aimed to determine and compare the most common dominant affective 
 temperaments in as patients and in a healthy control group using the temperament evaluation 
 of memphis , pisa , paris and san diego auto questionnaire ( temps - a ) and to examine the 
 relationship in as patients between existing depression and anxiety levels and levels of 
 pain , disease activity , and quality of life and the dominant affective temperament .
fifty - one patients diagnosed with axial spondiloartropathy ( spa ) and forty - two age- and 
 gender - matched control subjects were included in this study .
the radiographic arm of the 
 assessment of spondyloarthritis international society ( asas ) identification was used for 
 identification of axial spa .
baseline assessments were completed by trained investigators using identical questionnaires 
 that included demographic information ( age , gender , and education ) , disease duration , 
 medications ( non - steroidal anti - inflammatory drugs ( nsaids ) , anti - tumor necrosis factor 
 ( tnf ) ) , serum c - reactive protein level ( crp ) , erythrocyte sedimentation rate ( esr ) , pain by 
 visual analog scale ( vas ) , and measurements for disease activity , functional status , 
 psychological status , health assessment , and affective temperament .
patients with any kind of collagen tissue disorders or any other inflammatory diseases , 
 malignancies , diseases of the central nervous system , chronic kidney disease , chronic liver 
 disease and thyroid diseases besides the as were excluded .
patients who were being treated 
 for a psychiatric disorder or who had a lifetime history of psychiatric disorder , patients 
 with mental retardation , and patients who had diseases of the brain or central nervous 
 system , fibromyalgia , diabetes mellitus , hypertension , or were pregnant were also 
 excluded .
all assessments were made by the same physician and standardized case report forms were 
 filled out .
for all patients , written informed consent was obtained , and the protocol of the 
 study was approved by the local ethics committee of namk kemal university ( no : 
 2014/116 ) .
disease activity and functional status ; the bath ankylosing spondylitis disease activity 
 index ( basdai ) is an index used to determine the activity of as .
the index includes six 
 questions about the levels of neck , back , lower back , and hip pain , fatigue , pain and 
 swelling at peripheral joints , tenderness with palpation at several areas of the body , and 
 morning stiffness , including its duration .
the mean value of the last two questions is 
 calculated together and the mean value of the resulting five items is then obtained .
the bath ankylosing spondylitis functional index ( basfi ) was used to assess patient 
 function .
this scale is based on 10 questions about daily functioning , each scored on a 
 10-cm visual analogue scale ( vas ) , reflecting status over the past month .
the reliability and validity of the 
 turkish version of basdai and basfi have already been demonstrated17 , 18 .
pain ; in the vas , the two extremes of the parameter being assessed are written at the edges 
 of a 100-mm line , and the patient is asked to draw a line to or put a mark at the place that 
 would indicate his or her status . for pain ,
 no pain  is written at one edge and  very 
 severe pain  at the other edge .
the distance from the point of  no pain  to the patient s 
 mark defines his or her pain level .
this test has proven itself over a long period of time and is widely accepted in 
 the literature .
psychological status ; affective temperament , the turkish version of the temps - a scale was 
 used to determine the dominant affective temperament of the subjects .
volunteers were asked 
 to complete the temps - a . the validity and reliability of temps - a has been proven in many 
 languages , including in turkish by vahip et al20 . the turkish version of the scale consists of 99 items .
its 99 constituent items inquire about the subject s life - long traits along 
 depressive , cyclothymic , hyperthymic , irritable , and anxious lines .
no when considering their life experience . cutoff scores to determine the dominant 
 temperament are 13 for depressive mood ( 18 items ) , 18 for cyclothymic ( 19 items ) , 20 for 
 hyperthymic ( 20 items ) , 13 for irritable ( 18 items ) , and 18 for anxious ( 24 items ) .
it is 
 possible to have more than one dominant affective temperament8 , 20 , 21 .
the beck depression inventory ( bdi ) is a self - report inventory that measures the severity 
 of depression22 .
the bdi includes 21 
 items scored between 0 and 3.the turkish version was validated by hisli23 .
the beck anxiety inventory ( bai ) is a self - report 
 inventory consisting of 21 items scored between 0 and 3 that measures the frequency of 
 physiological and other symptoms of anxiety experienced during the previous week24 .
measure of the quality of life ; disease - related quality of life was measured using the 
 ankylosing spondylitis quality of life ( asqol ) scale26 .
the reliability and validity of the turkish version of this 
 questionnaire was determined by duruz et al27 .
this questionnaire consists of 18 items with dichotomous responses 
 ( yes / no ) and is reliable and valid for measuring the health - related quality of life in 
 patients with as .
asqol has a total score ranging from 0 to 18 , with lower scores 
 representing better as - specific quality of life measures of laboratory variables ; the erythrocyte sedimentation rate ( esr ) was measured 
 using the wintergreen method ( mm / h ) , and serum c - reactive protein ( crp ) level was measured 
 by nephelometry ( mg / dl ) .
statistical analyses ; spss for windows version 17.0 software was used for the statistical 
 analyses of our study data .
mean standard deviation ( sd ) was used to identify the data 
 related to the continuous variables , and number was used to identify the data related to the 
 categorical variables .
the kolmogorov - smirnov normalizing test was used to determine whether 
 the continuous variable data fit a normal distribution .
the comparison of the variables with 
 normal distribution was carried using an unpaired t - test , and the comparison of the 
 variables without normal distribution was carried out using the mann - whitney u - test .
the 
 comparison of categorical variables was done using pearson s  test , and the 
 relation among continuous variables was studied using spearman rank correlation analysis . 

multiple linear regression analysis was used to explain the relationship between one 
 continuous dependent variable from two or more independent variables .
the data from 51 patients with as ( 32 female ) and 42 healthy controls ( 32 female ) were 
 analyzed .
demographic characteristics and clinical and laboratory features of the patients 
 are summarized in table 1table 1.demographic , clinical and laboratory variablesvariablesas ( n=51)mean  sdcontrol ( n=42)mean  sdage ( years)38.7  10.437.8  4.6gender
f / m32/1932/10crp7.3  8.9esr25  20.8hla - b27 seropositivity n ; % 27/3 ; 81.8vas ( 0100  mm)47  26.4basfi3.1  2.5basdai4.0  1.8asqol7.0  4.4bdi10.2  9.77.5  5.9bai12.3  12.2 * 5.3  3.2duration of symptoms ( years)12.2  7.7duration of education ( years)9.5  3.3nsaid use n ; % 41 , 81.4anti - tnf use n ; % 36 , 70.6esr : erythrocyte sedimentation rate ; crp : c - reactive protein ; vas : visual analog 
 scale ; basdai : bath ankylosing spondylitis disease activity index ; basfi : bath 
 ankylosing spondylitis functional index ; bdi : beck depression inventory ; bai : beck 
 anxiety inventory ; asqol : ankylosing spondylitis quality of life ; nsaid : non - steroid 
 anti - inflammatory drugs .
esr : erythrocyte sedimentation rate ; crp : c - reactive protein ; vas : visual analog 
 scale ; basdai : bath ankylosing spondylitis disease activity index ; basfi : bath 
 ankylosing spondylitis functional index ; bdi : beck depression inventory ; bai : beck 
 anxiety inventory ; asqol : ankylosing spondylitis quality of life ; nsaid : non - steroid 
 anti - inflammatory drugs . *
significant difference from the baseline value ( p<0.05 ) temps - a scores of the patients and controls are shown in table 2table 2.distribution of temperament scores in the as and control groupsvariablesas ( n=51)mean  sdcontrol ( n=42)mean  sddepressive 6.2  3.96.9  3.3cyclothymic 7.8  5.06.9  4.3hyperthymic 9.6  4.39.2  4.4irritable 3.9  4.14.0  4.1anxious 7.4  6.76.0  4.9*significant difference from the baseline value ( p<0.05 ) . there was no significant difference in the distribution of temperament scores 
 between the as and control groups ( table 2 ) .
* significant difference from the baseline value ( p<0.05 ) no difference was observed in patients between temperament , bdi , and bai levels according 
 to the use of anti - tnf therapy ( table 
 3table 3.temperament scores of patients according to the use of anti - tnf therapy and 
 comparison of the bdi and bai scoresvariablesanti - tnftreatment ( n=36)mean  sdanti - tnfnon - treatment ( n=15)mean  sddepressive6.1  4.46.6  2.6cyclothymic 7.7  5.38.0  4.3hyperthymic9.5  4.89.8  3.2irritable3.8  4.44.0  3.4anxious7.6  6.87.0  6.9bdi9.9  9.811.1  9.8bai12.7  13.411.4  8.2bdi : beck depression inventory ; bai : beck anxiety inventory * significant difference 
 from the baseline value ( p<0.05 ) ) .
bdi : beck depression inventory ; bai : beck anxiety inventory * significant difference 
 from the baseline value ( p<0.05 ) temperament scores and bdi , bai values were compared with gender , duration of symptoms , 
 education , and disease activity .
depressive , cyclothymic and anxious temperament scores 
 along with the values of bdi and bai were higher in females .
the increase in anxious 
 temperament scores and bai values was statistically significant ( table 4table 4.comparison of temperament , bdi , and bai scores according to gender , duration of 
 symptoms , education , and disease activityvariablesdepressivecyclothymic hyperthymicirritableanxiousbdibaigenderf5.3  3.8 * 6.3  5.0 * 9.9  4.73.4  4.14.9  5.9 * 6.8  7.9 * 6.7  7.0*m7.8  3.710.4  3.89.1  3.84.7  4.011.7  5.915.2  10.220.6  10.2*duration of educaton 8 years7.3  3.8 * 8.6  5.710.2  4.24.4  5.09.7  7.4 * 13.5  8.8 * 17.8  13.6 * > 8 years4.2  3.76.5  4.79.3  4.63.3  3.65.0  6.18.7  9.47.5  8.1duraton of symptoms < 10 years6.0  3.58.6  4.410.4  4.24.5  3.48.1  6.512.1  11.114.7  14.8 > 10 years6.3  4.37.2  5.48.8  4.43.4  4.66.8  7.08.9  8.610.4  9.1basdai<4.05.4  3.66.7  5.09.9  4.83.4  3.66.0  5.98.6  8.911.1  11.54.07.0  4.29.0  4.89.2  3.94.4  4.59.0  7.312.0  10.513.6  12.60.1890.0850.6300.3470.1330.3800.216basdai : bath ankylosing spondylitis disease activity index ; bdi : beck depression 
 inventory ; bai : beck anxiety inventory . *
basdai : bath ankylosing spondylitis disease activity index ; bdi : beck depression 
 inventory ; bai : beck anxiety inventory . *
significant difference from the baseline value ( p<0.05 ) temperament , bdi , and bai scores , age , duration of symptoms , duration of education , basdai , 
 asqol , and correlations with vas are summarized in table 5table 5.correlation of temperament scores with the duration of symptoms , duration of 
 education , and basdaivariablesageduration of symptomsduration of educatonbasdaiasqolvasdepressiver0.1520.0260.470 * 0.296 * 0.2500.280*cyclothymic r0.1320.259*0.2700.278 * 0.1150.408*hyperthymicr0.2240.1370.0210.1290.1140.266*irritabler0.1110.295*0.2260.1780.0210.239anxiousr0.0580.1650.433 * 0.330 * 0.294 * 0.373*bair0.1870.1020.522 * 0.2590.343 * 0.42bdir0.1510.1860.367 * 0.2620.3240.020basdai : bath ankylosing spondylitis disease activity index ; bdi : beck depression 
 inventory ; bai : beck anxiety inventory .
basdai : bath ankylosing spondylitis disease activity index ; bdi : beck depression 
 inventory ; bai : beck anxiety inventory . *
significant difference from the baseline 
 value ( p<0.05 ) there was a negative correlation between depressive and anxious temperament , bdi and bai 
 scores , and the duration of education .
positive correlation was only found between irritable 
 temperament scores and duration of symptoms . there was a positive correlation between the 
 basdai and the depressive and cyclothymic scores .
there was a positive correlation between asqol and the 
 anxious temperament , bdi , and bai scores .
depressive , cyclothymic , and anxious temperaments 
 and bai and bdi scores were positively correlated with vas .
temperament , basfi , bdi , and bai scores have been found to have no correlation between hla 
 b27 seropositivity , sedimentation , and crp values .
depressive , cyclothymic , irritable , and anxious temperament scores were positively 
 correlated with bai and bdi ( table 6table 6.association of temperament scores with bai and bdibaibdidepressiver0.579 * 0.454*cyclothymic r0.582 * 0.506*hyperthymicr0.1560.106irritabler0.4500.449*anxiousr0.6910.576*bdi : beck depression inventory ; bai : beck anxiety inventory ; vas : visual analog 
 scale .
bdi : beck depression inventory ; bai : beck anxiety inventory ; vas : visual analog 
 scale . *
this study , in which the turkish version of temps - a was used , is the first study to 
 evaluate affective temperament in turkish as patients .
no statistically significant 
 difference was determined between the as patients and the control group with respect to the 
 distribution of temperament subtypes .
various previous studies have shown similar results in the 
 gender distribution of the five dominant affective temperaments , with females found to be 
 more depressive , anxious , and cyclothymic26 , 28 .
individuals 
 with a depressive temperament display low energy and emotional state and negative cognition . 

those with an anxious temperament have a tendency to be overly concerned about the welfare 
 of themselves and those close to them .
a cyclothymic temperament shows rapid and unexpected 
 swings between the polar opposite emotional states of depressive and hyperthymic30 . in the current study ,
the anxious and 
 depressive temperament scores were higher in those with low levels of education and there 
 was a significant positive correlation between the duration of symptoms and irritable 
 temperament . in a study by litaem , it was reported that as the duration of the disease 
 increased , the irritable and hyperthymic temperament scores were found to be significantly 
 higher10 .
irritable temperament forms with a highly variable mixture of dysthymic and hyperthymic 
 features and manifests with habitual complaining , excessively critical attitudes , and 
 outbursts of anger30
. there may be a 
 relationship between high irritable temperament scores and longer duration of symptoms .
the 
 biological and psychological results of a chronic disease such as as may predispose an 
 individual to the development of an irritable temperament .
studies have shown that 
 depressive and anxiety symptoms were found at high levels in as31 , 32 . in the current 
 study ,
only the rates of anxiety were determined to be statistically significantly high 
 compared to the control group .
the bdi and bai values were high in females and those with 
 less than 8  years of education .
there is known to be a relationship between disease activity in as and a patient s 
 psychological status and quality of life34 .
several studies have found a positive correlation between an 
 increase in disease activity and depression and anxiety symptoms and a reduction in quality 
 of life35 . in those with high basdai and 
 vas values in the current study , the depressive , cyclothymic , and anxious temperament scores 
 were higher .
this shows that the affective temperament in as patients was affected by 
 disease activity and pain .
the correlation between the asqol values and the anxious 
 temperament subtype scores demonstrates that anxious affective temperament affected quality 
 of life . in a study by janowski , a relationship
the role of stress in the etiology of as has not yet been fully understood , but the 
 temperament characteristics of the patient may affect the success of the struggle against 
 stress10 .
affective temperament can be 
 included in the factors creating a predisposition to the development of affective disorders 
 such as depression37 .
therefore , just as 
 depression and anxiety symptoms could be a significant comorbidity in as patients , it could 
 also be form of the infrastructure of temperament .
the results of this study have shown a significant relationship between bai and bdi scores 
 and depressive , cyclothymic , irritable , and anxious temperaments .
this result suggests that 
 affective temperament could be a risk factor for depression and anxiety in as patients 
 ( table 7table 7.multiple linear regression analysis of temperament scores with bai and 
 bdibaibdiconstant4.4264.555depressive0.4420.299cyclothymic0.0950.122hyperthymic0.2090.312irritable0.9590.321anxious1.628 * 0.687*bai : beck anxiety inventory ; bdi : beck depression inventory .
* significant difference 
 from the baseline value ( p<0.05 ) this comparative study is the first to evaluate affective temperament in as patients by 
 evaluating the relationship between the dominant affective temperament and existing 
 depression and/or anxiety .
patients with additional diseases such as diabetes mellitus , 
 hypertension , or fibromyalgia were not included in the study .
therefore , it was possible to 
 evaluate the relationship between pain , disease activity , disability , and temperament .
it 
 was determined that as the depressive and anxiety symptoms of affective temperament 
 increased in patients with as , so disease activity increased and quality of life 
 deteriorated .
therefore , the importance of psychosocial support for as patients must be 
 considered in the prognosis , and it can be suggested that the determination of the affective 
 temperament of as patients would be helpful for clinicians in the treatment and motivation 
 of patients .
the factors explaining physical activity are unclear for axspa patients : is 
 physical activity related to disease characteristics , e.g. disease activity , severity , or 
 treatment , or to patient - related characteristics ? whether the level of physical activity is 
 related to disease activity is uncertain , some studies finding no correlation38 , others reporting that patients with high 
 disease activity exercised less39 , 40 or reversely , more41 .
furthermore , other factors such as patients willingness 
 and motivations to exercise may be more important to explain physical activity .
a better 
 knowledge of physical activity levels and their causes or related factors in axspa would 
 allow physicians to target this aspect of disease management .
the number of cases included in this study was relatively 
 low and it was a cross - sectional study . there is a need for further prospective studies to 
 evaluate the effects of temperament on as patients .
 [ purpose ] this study aimed to compare the most common dominant affective temperaments in 
 ankylosing spondylitis patients and investigate the relationship between the dominant 
 affective temperaments and pain levels , disease activity , quality of life , current 
 depression , and anxiety level in ankylosing spondylitis patients . 
 [ subjects and methods ] 
 fifty - one patients diagnosed with axial spondiloartropathy and forty - two age- and 
 gender - matched control subjects were included in this study . 
 disease duration , erythrocyte 
 sedimentation rate , serum c - reactive protein , pain by the visual analog scale , disease 
 activity by the bath ankylosing spondylitis disease activity index , functional status by 
 the bath ankylosing spondylitis functional index ; psychological status by the beck 
 depression inventory , beck anxiety inventory and overall health assessment by the 
 ankylosing spondylitis quality of life scale were assessed in patients . the turkish 
 version of the temperament evaluation of memphis , pisa , paris and san diego auto 
 questionnaire was used to determine the dominant affective temperament . [ results ] 
 there 
 was no statistical difference in the distribution of temperament subtypes between patients 
 with ankylosing spondylitis and the controls . 
 depressive , anxious , and cyclothymic 
 temperament scores were higher in patients with high values on the bath ankylosing 
 spondylitis functional index and visual analog scale . 
 there was a correlation between 
 anxious subtypes of affective temperament scores and the value of ankylosing spondylitis 
 quality of life scale . 
 correlation analysis also found depressive , cyclothymic , irritable , 
 and anxious temperament and psychiatric symptoms to be significantly related . 
 [ conclusion ] 
 affective temperament may contribute to symptoms of depression and anxiety in patients 
 with ankylosing spondylitis and may increase disease activity and may reduce their quality 
 of life . 