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Psychiatry Investig > Volume 22(6); 2025 > Article
Jang, Kwon, Yu, Lee, Yoon, Lee, Park, Ryoo, Park, Lee, Lee, Won, Ha, and Myung: Exploring the Correlation of Childhood Trauma With the Behavioral Activation and Inhibition System in Major Depressive Disorder and Bipolar I and II Disorders

Abstract

Objective

Studies examining the relationship between the behavioral inhibition system (BIS), behavioral activation system (BAS), and mood disorders in individuals who have experienced childhood trauma remain limited. This study aimed to investigate the associations between childhood trauma, the BIS/BAS, and mood disorders.

Methods

This study included 1,026 patients with major depressive disorder (MDD, n=338), bipolar I disorder (BD-I, n=152), bipolar II disorder (BD-II, n=536), and 734 comparisons. The Childhood Trauma Questionnaire-Short Form (CTQ) and BIS/BAS scale were used for evaluation.

Results

Differences in the CTQ and BIS/BAS scores among the patient and comparison groups were examined. Patients in the BD-II group had significantly higher total BIS scores than those in the comparison, MDD, and BD-I groups. Patients with BD-I had significantly higher total BAS scores than those with MDD. The CTQ and total BIS scores were positively correlated, and the total BIS scores showed a significant correlation with emotional neglect and emotional abuse subscale scores. In contrast, no correlation was observed between the CTQ and total BAS scores or between MDD and the total BIS/BAS scores.

Conclusion

Differences in childhood trauma and behavioral patterns were observed based on mood disorders. Hence, this study provides valuable insights for future studies on how childhood trauma affects the BIS/BAS in various mental disorders.

INTRODUCTION

Childhood trauma can have long-term adverse effects. According to the National Child Traumatic Stress Initiative [1], over two-thirds of children have at least one traumatic experience before the age of 16 years, which can include domestic violence, neglect, and psychological, physical, or sexual abuse. Early exposure to childhood trauma leads to a higher risk of deficits in neurocognitive and emotion regulation functions and the later development of depression [2]. It can also increase sensitivity to potential threats and reduce the expectation of rewards among individuals [2]. Childhood mistreatment and trauma often occur at home with primary caregivers or parents, and children may develop deficiencies in emotional regulation due to insufficient exposure to modeling appropriate emotional labeling, expressions, and behaviors [3].
The behavioral inhibition system (BIS) and behavioral activation system (BAS) are widely recognized as stable personality traits in Gray’s Reinforcement Sensitivity Theory [4]. BIS/BAS influences individual responses to stimuli, including rewards and punishments, shaping traits and behaviors over time [5]. Previous studies have demonstrated that BIS/BAS sensitivities are associated with various behavioral patterns that differ by sex, cultural context, and neurophysiological measures [6,7]. In addition, differences in BIS/BAS traits have been observed in the context of different childhood adverse events and emotional stimuli [8]. The BIS detects threats, punishments, and consequences affecting behavior, whereas the BAS regulates motivation and goal-directed behavior [9]. Both systems play a role in childhood development and emotion regulation; an imbalance in either of them is associated with insensitivity to rewards and anhedonia [10]. Children with higher BIS sensitivity are likely to avoid peer conflicts, whereas those with lower BAS sensitivity are more likely to engage in classroom tasks [11]. A previous study has also demonstrated that individuals who experienced childhood trauma are at risk for impairments in executive functioning (such as goal-oriented behaviors and self-regulation) during behavioral inhibition tasks [12]. In addition, the BIS and BAS are associated with vulnerability and the development of psychiatric disorders [13,14]. Previous studies have demonstrated that major depressive disorder (MDD) decreases reward responsiveness and BAS sensitivity [15], whereas hypomania increases reward sensitivity [16].
Previous studies have demonstrated that childhood trauma critically impacts vulnerability to mood disorders, including MDD, bipolar I disorder (BD-I), and bipolar II disorder (BD-II) [17,18]. A previous study reported that childhood trauma caused depressive symptoms in mood disorders, especially in cases involving emotional and physical abuse or neglect [19]. Individuals with bipolar disorder (BD) and less severe mania symptoms exhibit diminished levels of motivation- and reward-seeking behaviors linked to the BAS [20]. Furthermore, those with BD and a history of childhood trauma exhibit more pronounced impairments in the BIS [21]. Since childhood trauma and sensitivity to the BIS and BAS lead to a higher risk of mood disorders, interrelations may exist between their impact on mood disorders.
Multiple studies have investigated the association between childhood trauma and mood disorders or BIS and BAS (BIS/BAS). However, studies explaining the association between BIS/BAS and mood disorders with childhood trauma history are lacking. Therefore, this study aimed to examine the relationship between childhood trauma and the BIS/BAS in individuals with MDD, BD-I, and BD-II. The study hypothesized that 1) childhood trauma and BIS/BAS would have a significant association, 2) the association between BIS/BAS sensitivity and each mood disorder would differ, with differences among patients with MDD, BD-I, and BD-II, and 3) patient and comparison groups would demonstrate various relationships between childhood trauma and BIS/BAS, with the patient group showing stronger associations than the comparison group.

METHODS

Participants and ethical statements

Participants were diagnosed with mood disorders according to the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition [22], at the mood disorder clinic in South Korea between September 2015 and June 2021. All relevant data, including age, sex, education, job, marital status, drinking, smoking, and hospitalization history, were collected. Diagnoses were confirmed by board-certified psychiatrists using the Mini-International Neuropsychiatric Interview [23] and medical history. The comparison group was anonymously recruited from the general population using an online survey platform, selected for its effectiveness in reaching a large and diverse population quickly and at minimal cost. Participants were included based on balanced representation across sex and age groups and were excluded if they self-reported a prior diagnosis of any psychiatric disorder. Participation was voluntary, and upon completing the questionnaire, participants were provided with a brief summary of the results.
This study adhered to the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board. The need for informed consent from the patients was waived because their data were obtained through medical records. The need for informed consent from the comparison group was also waived because the researchers did not have access to the personal information of the participants and conducted data analyses using anonymized survey data. The study protocol was approved by the Institutional Review Board of SNUBH (IRB No. B-2104-679-103, approved Aril 5, 2021).

Clinical instruments

BIS/BAS scale

The BIS/BAS scale 9 is a 20-item self-reported questionnaire with a BIS subscale (focuses on sensitivity to aversive events: seven items) and three BAS subscales used to measure: 1) reward responsiveness (positive responses to reward occurrence or its anticipation: five items), 2) drive (ensures persisting pursuit of desired goals: four items), and 3) fun seeking (desires for new rewards and willingness to engage in potentially rewarding activities: four items). The questionnaire used a four-point Likert scale (1, very true for me; 2, somewhat true for me; 3, somewhat false for me; and 4, very false for me). The total scores ranged from 20 to 80, and higher scores indicated greater traits as measured by the scale. This study utilized the Korean version of the BIS/BAS scale, which showed high internal consistency for the full scale and subscales (Cronbach’s alpha: 0.85 and 0.71 for the BIS and BAS subscales, respectively) [24].

Childhood Trauma Questionnaire-Short Form

The Childhood Trauma Questionnaire-Short Form (CTQ) is a 28-item retrospective self-reported questionnaire designed to assess childhood and adolescent (<18 years) adverse experiences on a five-point Likert scale (1: never true, 2: rarely true, 3: sometimes true, 4: often true, and 5: very often true). It comprises five trauma subscales: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. A modified CTQ score was used after eliminating scores related to minimization/denial (items 10, 16, and 22). The total scores ranged from 25 to 125, with each subscale scoring between 5 and 25. This study used the Korean version of the CTQ, which revealed strong internal consistency across the five subscales (Cronbach’s alpha: 0.78-0.95) [25].

Statistical analysis

The independent samples t-test was used to analyze the differences in demographic and clinical variables between the groups for continuous variables. Data on the marital status of patients was initially collected as married, single, divorced, or widowed. However, during the analysis, they were further categorized as married and others. The chi-squared test was used to compare categorical variables. An analysis of covariance was conducted to compare the BIS/BAS and CTQ scores. Post-hoc testing with Bonferroni correction was used to ascertain the trend in differences between the groups. Partial correlation coefficients were conducted using residuals from the multiple regression models to explore the associations between BIS/BAS and CTQ scores while controlling for the influence of confounding factors such as age, sex, education, employment status, marital status, alcohol use status, smoking status, and psychiatric first-degree family history. This residual-based approach enabled the isolation of the influence of these confounders and examined the unique association between BIS/BAS and CTQ scores. This approach is conceptually aligned with regression analysis in that both isolate the adjusted relationships, with partial correlation providing a standardized measure of association. Furthermore, the correlation between the BIS and BAS was calculated under identical conditions. All statistical analyses were two-tailed, and statistical significance was defined as p<0.05. Bonferroni correction was applied to correct type I errors by multiplying the unadjusted p-value by the total number of tests. These analyses were performed using R version 4.2.2 (R Foundation for Statistical Computing).

RESULTS

Clinical and demographic characteristics

This study analyzed data from 1,026 patients (MDD [n=338], BD-I [n=152], and BD-II [n=536]) and 734 individuals in the comparison group. The clinical and demographic characteristics are presented in Table 1. The mean age of the sample was 35.95 years (standard deviation [SD]: 11.88), with an age range of 16-70 years. Participants included 630 males (35.80%) and 1,130 females (64.20%), with 285 males (27.78%) and 741 females (72.22%) in the patient group and 345 males (47.00%) and 389 females (53.00%) in the comparison group. Statistical differences in age (t(1)=7.53, p<0.001), sex (t(1)=-8.31, p<0.001), education (t(1)=8.44, p<0.001), employment status (t(1)=14.62, p<0.001), marital status (t(1)=6.60, p<0.001), alcohol use status (t(1)=11.45, p<0.001), and smoking status (t(1)=3.48, p<0.01) were observed between the patient and comparison groups.

BIS/BAS and CTQ scores according to groups

Significant differences in the total BIS scores were observed between groups (F3,1756=96.12, p<0.001) (Figure 1 and Table 2). In particular, patients in the BD-II group had significantly higher total BIS scores (mean±SD: 19.72±2.39) than those in the comparison (18.63±2.40, p<0.001), MDD (19.34±2.30, not significant [n.s.]), and BD-I (18.72±3.13, p<0.01) groups.
Significant differences in the total BAS scores were observed across the groups (F3,1756=17.32, p<0.001) (Table 2). Particularly, patients with BD-I had significantly higher total BAS scores (mean±SD: 36.86±7.74) than those with MDD (33.70±7.01, p<0.01). Among the subscales, the reward responsiveness scores in the BD-II group (mean±SD: 15.12±2.91) were significantly higher than those in the comparison (14.60±2.30, p<0.01) and MDD (14.04±2.92, p<0.001) groups. The drive subscale scores in patients with BD-I (mean±SD: 11.13±2.85) were significantly higher than those in patients with MDD (10.01±2.67, p<0.001). Patients with BD-II (mean±SD: 10.87±2.79) also had significantly higher drive subscale scores than those with MDD (10.01±2.67, p<0.001). Patients with BD-I (mean±SD: 10.89±3.08) had significantly higher fun-seeking scores than those with MDD (9.65±2.56, p<0.001). Similarly, fun-seeking scores in patients with BD-II (mean±SD: 10.76±2.92) were significantly higher than those in patients with MDD (9.65±2.56, p<0.001). In contrast, the drive subscale scores in patients with MDD (mean±SD: 10.01±2.67) were significantly lower than those in patients with BD-I (11.13±2.85, p<0.001) and BD-II (10.87±2.79, p<0.001). The fun-seeking scores in patients with MDD (mean±SD: 9.65±2.56) were also significantly lower than those in patients with BD-I (10.89±3.08, p<0.001) and BD-II (10.76±2.92, p<0.001). Multiple differences were also observed in the total CTQ scores and subscales in the analysis of covariance with Bonferroni post-hoc comparisons.

Relationship between childhood trauma and behavioral systems in the patient and comparison groups

Partial correlation analyses showed that the total CTQ scores positively correlated with the total BIS scores (rho=0.171, corrected p<0.001 for all participants; rho=0.137, corrected p<0.001 for the comparison group; rho=0.131, corrected p<0.001 for all patients) (Figure 2, Table 3, and Supplementary Tables 1 and 2). These findings showed that individuals with higher childhood trauma scores inhibited their behaviors more. In contrast, this study did not observe any correlation between the total CTQ and BAS scores.
At the CTQ subscale level, emotional abuse was the factor most positively correlated with the total BIS scores (rho=0.194, corrected p<0.001 in all participants; rho=0.160, corrected p<0.001 in the comparison group; rho=0.144, corrected p<0.001 in all patients) (Figure 2, Table 3, and Supplementary Tables 1 and 2). In addition, the CTQ emotional neglect subscale negatively correlated with the total BAS score (rho=-0.109, corrected p<0.001 in all participants) (Figure 2, Table 3, and Supplementary Tables 1 and 2).

Relationship between childhood trauma and behavioral systems based on mood disorders

In the subgroup analyses, the CTQ emotional neglect subscale positively correlated with the total BIS score in the BD-II group (rho=0.135, corrected p<0.05) (Supplementary Table 3). A negative correlation was observed between the CTQ emotional neglect subscale and BAS reward responsiveness subscale in the MDD group (rho=-0.193, corrected p<0.001) (Figure 2 and Supplementary Table 4). No correlation was observed between the CTQ and BIS/BAS scores in the BD-I group (Figure 2 and Supplementary Table 5). In the BD-II group, the total CTQ scores significantly correlated with the total BIS scores (rho=0.125, corrected p<0.05) (Figure 2 and Supplementary Table 3).

Relationship between childhood trauma and behavioral systems based on sex

The total CTQ score positively correlated with the total BIS score in both male and female participants (rho=0.176 and 0.161, corrected p<0.001 for all male and female participants, respectively) (Supplementary Figures 1, 2 and Supplementary Table 6). At the CTQ subscale level, the emotional neglect subscale was most positively correlated with the total BIS scores in all male participants (rho=0.199, corrected p<0.001). In comparison, the most positive correlation in all female participants was observed between emotional abuse and total BIS scores (rho=0.197, corrected p<0.001). The total CTQ scores also negatively correlated with the BAS drive subscale scores in all female participants (rho=-0.136, corrected p<0.001). The CTQ emotional neglect subscale was most negatively correlated with the drive subscale scores in all female participants (rho=-0.211, corrected p<0.001). In comparison, the only negative correlation observed in all male participants was between emotional neglect and drive subscale scores (rho=-0.098, corrected p<0.05).
In the comparison group, the total CTQ score positively correlated with the total BIS score (rho=0.183, corrected p<0.01) (Supplementary Figures 3, 4 and Supplementary Table 7) and negatively correlated with the total BAS score (rho=-0.156, corrected p<0.05) in male participants. The CTQ emotional abuse (rho=0.182, corrected p<0.01) and emotional neglect (rho=0.193, corrected p<0.01) subscales positively correlated with the total BIS scores in all male participants. In addition, the BAS drive subscale scores were most negatively correlated with the CTQ emotional neglect scale (rho=-0.224, corrected p<0.01). No correlation was observed between the CTQ subscales and BIS/BAS scores in female participants. Meanwhile, the total CTQ scores in all patient groups positively correlated with the total BIS and BAS scores (rho=0.114, corrected p<0.01 in all male participants; rho=0.164, corrected p<0.05 in all female participants) (Supplementary Figures 5, 6 and Supplementary Table 8). The CTQ emotional neglect subscale score was the most negatively correlated with the BAS drive subscale score in all female participants (rho=-0.236, corrected p<0.01).

Relationship between the BIS and BAS

Further partial correlation analyses were conducted between the BIS and BAS. The total BIS scores positively correlated with the total BAS scores (rho=0.160, corrected p<0.001 for all participants; rho=0.153, p<0.001 for the comparison group; rho=0.189, corrected p<0.001 for all patients) (Supplementary Tables 9-11). No correlation was observed between the total BIS and BAS scores in the MDD group (rho=0.214, n.s.) (Supplementary Table 12). These results suggest that behavioral inhibition increases with activity in patients with BD, whereas no correlation exists between inhibition and activity in patients with MDD. The total BIS scores in the BD-I and BD-II groups significantly correlated with the total BAS scores (rho=0.261, corrected p<0.01 BD; rho=0.173, corrected p<0.001) (Supplementary Tables 13 and 14).

DISCUSSION

This study investigated the association between childhood trauma, as well as behavioral inhibition and activation systems in patients with MDD, BD-I, and BD-II and a comparison group. Significant group differences in total BIS/BAS scores were observed between childhood trauma and mood disorders and in the patient and comparison groups. Patients with BD-II had significantly higher total BIS scores than those in the comparison, BD-I, and MDD groups. Patients with BD-I had higher total BAS scores than those in the comparison, BD-II, and MDD groups. Additional statistical analyses showed a positive correlation between the CTQ and total BIS scores; emotional neglect and emotional abuse stood out more prominently than other subscales in the BIS. However, no significant correlation was observed between CTQ and total BAS scores or between MDD and total BIS/BAS scores.
Several studies have demonstrated that the BIS/BAS has a unique relationship with depressive and manic symptoms, as well as emotional regulation [26,27]. Patients with BD show elevated sensitivity to BAS compared to patients with MDD during depressive episodes [26]. The findings of this study are consistent with those of previous studies, as differences in BIS/BAS scores were observed between the patient and comparison groups. The BD-II group showed significantly higher total BIS scores than the comparison, MDD, and BD-I groups. In contrast, the BD-I group showed significantly higher total BAS scores than the other groups. These results suggest that different diagnoses and personality traits in patient groups may impact sensitivity toward their behaviors. BAS is activated by characteristics of goal-oriented or reward-seeking behaviors [28]. A previous study on patients with BAS hypersensitivity demonstrated that the vulnerability of BD can lead to excessive BAS activation and the experience of impulsiveness and reward-seeking behaviors [29,30]. BIS/BAS sensitivity also differs based on the mood episode of patients. BAS hypersensitivity is associated with the onset of hypomanic or manic episodes in BD, whereas BIS hypersensitivity is associated with the onset of major depressive episode (MDE) [28]. Recognizing hypersensitivity of mood episode onset is helpful for both physicians and patients in managing symptoms.
Following up on BIS/BAS sensitivity in patients can assist physicians in identifying mood episodes at an earlier onset and facilitate the development of interventions to reduce their severity or duration [14]. For example, activating BAS in patients experiencing MDE can alleviate depression symptoms by leveraging the neural mechanisms of reward processing and enhancing emotional regulation [31]. The cognitive behavioral approach has shown effectiveness in increasing engagement in behavioral responses to rewards with respect to prefrontal cortex activities [32-34]. Thus, understanding the vulnerability of BIS/BAS is crucial for identifying symptoms and guiding treatments of patients with mood disorders.
Previous studies have reported that certain BIS/BAS scales are more associated with BD than MDD. Individuals with BD-I have higher drive- and fun-seeking subscale scores [22] and elevated BAS sensitivity [27]. Reward responsiveness is significantly associated with manic symptoms, indicating that individuals with BD who have higher reward responsiveness are at a greater risk of mania [35]. In contrast, lower reward responsiveness was exhibited in patients with MDD as anhedonia, alongside higher BIS scores [21]. Based on these findings, reward responsiveness was higher in the BD-II group than in the comparison and MDD groups. The BAS drive and fun-seeking subscale scores were significantly higher in the BD-I and BD-II groups than in the MDD group.
Subgroup analysis showed significant positive correlations between the CTQ and total BIS scores, suggesting that childhood trauma may increase BIS sensitivity. A previous study demonstrated that childhood trauma can impair long-term behavioral inhibition [10]. In this study, CTQ scores showed that BIS sensitivity is correlated with vulnerability and adverse events of childhood trauma. A previous study found that higher CTQ scores were associated with significantly higher impulsivity [36]. Another study demonstrated that the increase in impulsivity is related to emotional dysregulation, especially in patients with BD [37]. These findings indicate that childhood trauma increases BIS sensitivity and can contribute to emotional dysregulation [38].
Among the CTQ subscales, emotional abuse was positively correlated with the total BIS score. This result is consistent with a previous study showing that patients with BD who experienced emotional abuse have higher BIS sensitivity [39]. In addition, a significant positive correlation was observed between emotional neglect and BIS scores in patients with BD-II. Emotional abuse and neglect may affect patients with mood disorders differently in terms of neural functioning [40]. A previous study found that decreased neural functional networks due to childhood trauma supported vulnerability of brain development and emotional dysregulation [3]. Childhood trauma is linked to memory deficits 8 and executive functioning, which can affect inhibition response, an important cognitive function in BD [20].
Emotional abuse is associated with threat detection in the ventral amygdala, a brain region responsible for emotional salience and danger cues [41]. Conversely, emotional neglect is associated with more extensive changes in fronto-parietal networks and the dorsal amygdala, which are involved in advanced cognitive functions and emotional regulation [42]. This distinct neural mechanism may help explain various presentations of mood disorders. The increased threat sensitivity resulting from emotional abuse may amplify anxiety symptoms commonly observed in depression. Meanwhile, the widespread neural alterations associated with emotional neglect could disrupt reward processing and lead to the mood instability characteristic of BD [43].
To address BIS sensitivity, patients may receive benefits from psychosocial therapy, especially trauma-focused cognitive behavioral therapy (TF-CBT). Previous studies have shown that TF-CBT improves depressive symptoms by targeting specific types of traumas and the severity of symptoms [44] Other therapeutic options, such as eye movement desensitization and reprocessing [45] or mindfulness-based cognitive therapy, have shown benefits in managing emotional dysregulation, specifically in BD [46].
Our study showed no significant correlation between the BAS and total CTQ scores, especially with patients with MDD, suggesting hypoactive BAS in patients with MDD. A previous study found results parallel to the findings that childhood trauma was unrelated to fun-seeking or reward responsiveness [23]. This lack of correlation was attributed to anhedonia, low motivation, reward-seeking behaviors, and increased sensitivity to adverse stressors in patients with MDD [2]. Another previous study also demonstrated lower associations with BAS and MDD, noting that underactive BAS among patients with MDD remained stable after improvement of depressive symptoms and remission and positive experiences with behavioral therapy [47,48]. This result suggests that hypoactivity in BAS may serve as a vulnerability factor influencing personality traits among patients with MDD.
This study has a few limitations. It employed a cross-sectional design, which enabled the examination of associations between study variables but limited the ability to infer causal relationships. In addition, this design is prone to recall bias during data collection [49]. We did not collect the status of mood episodes and comorbid disorders while enrolling participants. Hence, their scores on the self-reported CTQ and BIS/BAS could have been affected, leading to inaccurate reports depending on their mood status and symptoms. Owing to our lack of data on the comorbidity of patients, we could not examine the correlations with other psychiatric disorders except for borderline personality disorder. The CTQ is a retrospective self-report questionnaire used in many studies to assess reliability among patients with childhood trauma [1,19]. However, self-reported measures are susceptible to subjective bias, as participants may not precisely describe their adverse experiences while completing the questionnaires [26]. Finally, patient samples were not randomly selected, and the groups were not proportionally matched. Furthermore, the psychiatric history of the comparison group was assessed solely based on self-reported data rather than through formal diagnostic evaluations. This reliance on self-reporting may have introduced bias, as undiagnosed or unreported psychiatric conditions could not be fully excluded. Therefore, this study may not be ideal for the generalized population. Despite these limitations, this cross-sectional study showed an association between the CTQ and BIS/BAS. Its findings and analyses allowed observation of the differences between mood disorders and the BIS/BAS. Thus, this study can help future studies to understand childhood trauma using the BIS/BAS in various psychopathological populations.
The findings of this study demonstrated an association between childhood trauma and behavioral inhibition and activation systems in patients with MDD, BD-I, and BD-II. The results indicated that patients with BD-II had significantly higher total BIS scores, whereas those with BD-I had higher total BAS scores. A positive correlation was observed between the CTQ and total BIS scores, with emotional neglect and emotional abuse correlating positively with total BIS scores. These findings enhance the understanding of the relationship between BIS, BAS, and mood disorders in the context of childhood trauma.

Supplementary Materials

The Supplement is available with this article at https://doi.org/10.30773/pi.2024.0247.
Supplementary Table 1.
Pearson correlation coefficient between CTQ scores, BIS, and BAS scores in comparison group (N=734)
pi-2024-0247-Supplementary-Table-1.pdf
Supplementary Table 2.
Pearson correlation coefficient between CTQ scores, BIS, and BAS scores in patients (N=1,026)
pi-2024-0247-Supplementary-Table-2.pdf
Supplementary Table 3.
Pearson correlation coefficient between CTQ scores, BIS, and BAS scores in bipolar II disorder (N=536)
pi-2024-0247-Supplementary-Table-3.pdf
Supplementary Table 4.
Pearson correlation coefficient between CTQ scores, BIS, and BAS scores in major depressive disorder (N=338)
pi-2024-0247-Supplementary-Table-4.pdf
Supplementary Table 5.
Pearson correlation coefficient between CTQ scores, BIS, and BAS scores in bipolar I disorder (N=152)
pi-2024-0247-Supplementary-Table-5.pdf
Supplementary Table 6.
Pearson correlation coefficient between CTQ scores, BIS, and BAS scores according to sex in all participants (N=1,760)
pi-2024-0247-Supplementary-Table-6.pdf
Supplementary Table 7.
Pearson correlation coefficient between CTQ scores, BIS, and BAS scores according to sex in comparison group (N=734)
pi-2024-0247-Supplementary-Table-7.pdf
Supplementary Table 8.
Pearson correlation coefficient between CTQ scores, BIS, and BAS scores according to sex in all patients (N=1,026)
pi-2024-0247-Supplementary-Table-8.pdf
Supplementary Table 9.
Pearson correlation coefficient between BIS and BAS scores in all participants (N=1,760)
pi-2024-0247-Supplementary-Table-9.pdf
Supplementary Table 10.
Pearson correlation coefficient between BIS and BAS scores in all comparison group (N=734)
pi-2024-0247-Supplementary-Table-10.pdf
Supplementary Table 11.
Pearson correlation coefficient between BIS and BAS scores in patients (N=1,026)
pi-2024-0247-Supplementary-Table-11.pdf
Supplementary Table 12.
Pearson correlation coefficient between BIS and BAS scores in major depressive disorder (N=338)
pi-2024-0247-Supplementary-Table-12.pdf
Supplementary Table 13.
Pearson correlation coefficient between BIS and BAS scores in bipolar I disorder (N=152)
pi-2024-0247-Supplementary-Table-13.pdf
Supplementary Table 14.
Pearson correlation coefficient between BIS and BAS scores in bipolar II disorder (N=536)
pi-2024-0247-Supplementary-Table-14.pdf
Supplementary Figure 1.
Partial correlation coefficients (p<0.05) are shown in the figure and partial correlation coefficients (p>0.05) are marked as X. Positive correlations are shown in blue color and negative correlations in red color. Color intensity is proportional to the partial correlation coefficients. Partial correlation plot between Childhood Trauma Questionnaire-Short Form (CTQ) scores, behavioral inhibition system (BIS), and behavioral approach system (BAS) score in all male participants (N=630).
pi-2024-0247-Supplementary-Fig-1.pdf
Supplementary Figure 2.
Partial correlation coefficients (p<0.05) are shown in the figure and partial correlation coefficients (p>0.05) are marked as X. Positive correlations are shown in blue color and negative correlations in red color. Color intensity is proportional to the partial correlation coefficients. Partial correlation plot between Childhood Trauma Questionnaire-Short Form (CTQ) scores, behavioral inhibition system (BIS), and behavioral approach system (BAS) score in all female participants (N=1,130).
pi-2024-0247-Supplementary-Fig-2.pdf
Supplementary Figure 3.
Partial correlation coefficients (p<0.05) are shown in the figure and partial correlation coefficients (p>0.05) are marked as X. Positive correlations are shown in blue color and negative correlations in red color. Color intensity is proportional to the partial correlation coefficients. Partial correlation plot between Childhood Trauma Questionnaire-Short Form (CTQ) scores, behavioral inhibition system (BIS), and behavioral approach system (BAS) score in all male comparison group participants (N=345).
pi-2024-0247-Supplementary-Fig-3.pdf
Supplementary Figure 4.
Partial correlation coefficients (p<0.05) are shown in the figure and partial correlation coefficients (p>0.05) are marked as X. Positive correlations are shown in blue color and negative correlations in red color. Color intensity is proportional to the partial correlation coefficients. Partial correlation plot between Childhood Trauma Questionnaire-Short Form (CTQ) scores, behavioral inhibition system (BIS), and behavioral approach system (BAS) score in all female comparison group participants (N=389).
pi-2024-0247-Supplementary-Fig-4.pdf
Supplementary Figure 5.
Partial correlation coefficients (p<0.05) are shown in the figure and partial correlation coefficients (p>0.05) are marked as X. Positive correlations are shown in blue color and negative correlations in red color. Color intensity is proportional to the partial correlation coefficients. Partial correlation plot between Childhood Trauma Questionnaire-Short Form (CTQ) scores, behavioral inhibition system (BIS), and behavioral approach system (BAS) score in all male patients (N=285).
pi-2024-0247-Supplementary-Fig-5.pdf
Supplementary Figure 6.
Partial correlation coefficients (p<0.05) are shown in the figure and partial correlation coefficients (p>0.05) are marked as X. Positive correlations are shown in blue color and negative correlations in red color. Color intensity is proportional to the partial correlation coefficients. Partial correlation plot between Childhood Trauma Questionnaire-Short Form (CTQ) scores, behavioral inhibition system (BIS), and behavioral approach system (BAS) score in all female patients (N=741).
pi-2024-0247-Supplementary-Fig-6.pdf

Notes

Availability of Data and Material

The datasets generated during and/or analyzed during the current study are available from the corresponding author (W.M.) on reasonable request.

Conflicts of Interest

The authors have no potential conflicts of interest to disclose.

Author Contributions

Conceptualization: Yoonjeong Jang, Sarah Soonji Kwon, Tae Hyon Ha, Woojae Myung. Data curation: Yoonjeong Jang, Chan Woo Lee, Hyeona Yu, Joohyun Yoon, Yun Seong Park, Hyun A Ryoo. Funding acquisition: Woojae Myung. Investigation: Yoonjeong Jang, Sarah Soonji Kwon, Hyeona Yu, Joohyun Yoon, Yun Seong Park, Hyun A Ryoo, Daseul Lee, Yejin Park, Hyuk Joon Lee. Methodology: Yoonjeong Jang, Sarah Soonji Kwon, Yeong Chan Lee, Chan Woo Lee, Hong-Hee Won, Tae Hyon Ha, Woojae Myung. Supervision: Hong-Hee Won, Tae Hyon Ha, Woojae Myung. Writing—original draft: Yoonjeong Jang, Sarah Soonji Kwon. Writing—review & editing: all authors.

Funding Statement

This research was supported by a National Research Foundation (NRF) of Korea Grant, funded by the Korean government (NRF-2021R1A2C4001779 and RS-2024-00335261 to WM). This research was also supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: RS-2023-KH136934). Additionally, this study was also supported by the NAVER Digital Bio Innovation Research Fund, funded by NAVER Corporation (Grant No. 37-2023-0140; WM) and Seoul National University Bundang Hospital (SNUBH) Research Fund (grant no. 18-2023-0009; WM). The funding body had no role in the study design, data collection, data analysis, data interpretation, or writing of this report. The corresponding author had full access to all the data in this study and had final responsibility for the decision to submit for publication.

Acknowledgments

None

Figure 1.
Violin plots for the distribution of behavioral inhibition system (BIS) and behavioral approach system (BAS) according to the groups. *p<0.005; **p<0.01; ***p<0.001.
pi-2024-0247f1.jpg
Figure 2.
Partial correlation plot between Childhood Trauma Questionnaire-Short Form (CTQ) scores, behavioral inhibition system (BIS), and behavioral approach system (BAS) scores. Partial correlation coefficients (p<0.05) are shown in the figure, and marked as X. Positive and negative correlations are shown in blue and red colors, respectively. The size of the blue or red color circle indicates the degree of correlation. Color intensity is proportional to the partial correlation coefficients. A: All participants (N=1,760). B: Comparison group (N=734). C: All patients (N=1,026). D: Major depressive disorder (N=338). E: Bipolar I disorder (N=152). F: Bipolar II disorder (N=536).
pi-2024-0247f2.jpg
Table 1.
Clinical and demographic characteristics of participants (N=1,760)
Characteristics Comparison group (N=734) Patient group (N=1,026)
p*
All patients (N=1,026) Major depressive disorder (N=338) Bipolar I disorder (N=152) Bipolar II disorder (N=536)
Age (yr) 38.38±10.68 34.22±12.39 38.35±13.14 33.89±11.75 31.70±11.36 <0.001
Sex <0.001
 Male 345 (47.00) 285 (27.78) 88 (26.04) 54 (35.53) 143 (26.68)
 Female 389 (53.00) 741 (72.22) 250 (73.96) 98 (64.47) 393 (73.32)
Education <0.001
 High school or below 101 (13.76) 307 (29.92) 114 (33.73) 36 (23.68) 157 (29.29)
 Others 633 (86.24) 749 (70.20) 224 (66.27) 116 (76.32) 379 (70.71)
Employment status <0.001
 Unemployed 231 (31.47) 664 (64.72) 209 (61.83) 98 (64.47) 357 (66.60)
 Employed 503 (68.53) 362 (35.28) 129 (38.17) 54 (35.53) 179 (33.40)
Marital status <0.001
 Single 381 (51.91) 612 (59.65) 159 (47.04) 97 (63.82) 356 (66.42)
 Married 332 (45.23) 364 (35.48) 158 (46.75) 49 (32.24) 157 (29.29)
 Divorced 18 (2.45) 48 (4.68) 20 (5.92) 6 (3.95) 22 (4.10)
 Widowed 3 (0.41) 2 (0.19) 1 (0.30) 0 (0.0) 1 (0.19)
Alcohol use status <0.001
 Former or current 571 (77.79) 541 (52.73) 157 (46.45) 87 (57.24) 297 (55.41)
 Never 163 (22.21) 485 (47.27) 181 (53.55) 65 (42.76) 239 (44.59)
Smoking status <0.01
 Former or current 260 (35.42) 283 (27.58) 70 (20.71) 45 (29.61) 168 (31.34)
 Never 474 (64.58) 743 (72.42) 268 (79.29) 107 (70.39) 368 (68.66)
Psychiatric hospitalization history -
 Yes - 283 (27.61) 53 (15.68) 75 (49.34) 155 (28.97)
 No - 742 (72.39) 285 (84.32) 77 (50.66) 380 (71.03)

Values are presented as mean±standard deviation or number (%).

* statistical significance between comparison group and total patient group;

t-test was used;

chi-squared test was used. -, not applicable

Table 2.
Total and subscale scores of the CTQ, BIS, and BAS in the patient and comparison groups
Comparison group (N=734) Patient groups (N=1,026)
Comparison vs. patients (t) F*† p Bonferroni post hoc
All patients (N=1,026) MDD (N=338) Bipolar I disorder (N=152) Bipolar II disorder (N=536)
CTQ
 Total score 41.99±14.63 48.93±17.24 46.44±17.12 46.61±17.35 51.16±17.01 9.11*** 33.62 <0.001 C<MDD***, C<BD-II***, C<BD-I*, MDD<BD-II***, BD-I<BD-II*
 Subscales
  Emotional abuse 8.07±3.79 10.64±5.19 9.59±5.03 9.72±4.83 11.55±5.24 12.01*** 59.25 <0.001 C<MDD***, C<BD-II***, C<BD-I***, MDD<BD-II***, BD-I<BD-II***
  Physical abuse 8.17±4.13 9.71±5.71 8.92±5.03 9.34±4.79 10.31±5.30 6.90*** 21.17 <0.001 C<BD-II***, C<BD-I*, MDD<BD-II**
  Sexual abuse 6.34±2.99 6.20±2.79 6.05±2.79 6.70±3.28 6.15±2.62 -1.02 2.27 0.079 N.S.
  Neglect emotional 10.91±4.67 13.96±5.99 13.57±6.01 12.74±6.08 14.56±5.89 12.01*** 49.95 <0.001 C<MDD***, C<BD-II***, C<BD-I**, BD-I<BD-II**
  Neglect physical 8.50±3.38 8.42±3.62 8.31±3.55 8.10±3.55 8.58±3.69 -0.43 0.97 0.405 N.S.
BIS
 Total score 18.63±2.40 19.44±2.51 19.34±2.30 18.72±3.13 19.72±2.39 15.33*** 96.12 <0.001 C<MDD***, C<BD-II***, BD-I<BD-II**
BAS
 Total score 36.05±5.14 35.76±7.41 33.70±7.01 36.86±7.74 36.75±7.30 -0.97 17.32 <0.001 C<MDD***, MDD<BD-II***, MDD<BD-I**
 Subscales
  Reward responsiveness 14.60±2.30 14.72±2.96 14.04±2.92 14.83±2.96 15.12±2.91 0.97 11.57 <0.001 C<MDD*, C<BD-II**, MDD<BD-II***, MDD<BD-I*
  Drive 10.98±1.95 10.62±2.79 10.01±2.67 11.13±2.85 10.87±2.79 -3.19** 14.07 <0.001 MDD<C***, MDD<BD-II***, MDD<BD-I***
  Fun seeking 10.47±2.01 10.42±2.88 9.65±2.56 10.89±3.08 10.76±2.92 -0.43 15.67 <0.001 MDD<C***, MDD<BD-II***, MDD<BD-I***

Values are presented as mean±standard deviation.

* p<0.05;

** p<0.01;

*** p<0.001, analysis of covariance (ANCOVA) was used between all groups;

ANCOVA with pairwise test after Bonferroni post-hoc was used between all groups;

statistical significance between comparison group and total patient group.

*† adjusted p-values with Bonferroni’s correction were calculated by multiplying raw p-values by the total number of multiple testing of subscales.

CTQ, Childhood Trauma Questionnaire-Short Form; BIS, behavioral inhibition system; BAS, behavioral approach system; C, comparison; MDD, major depressive disorder; BD-I, bipolar I disorder; BD-II, bipolar II disorder; N.S., not significant

Table 3.
Pearson correlation coefficient between the CTQ, BIS, and BAS scores in all participants (N=1,760)
Total score CTQ
Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect
BIS
 Total score 0.171*** 0.194*** 0.124*** 0.006 0.188*** 0.068*
BAS
 Total score -0.019 0.031 0.039 0.001 -0.109*** -0.012
 Reward responsiveness -0.025 0.028 0.023 -0.020 -0.085** -0.032
 Drive -0.052 -0.010 0.010 0.003 -0.135*** -0.029
 Fun seeking 0.028 0.061 0.066 0.022 -0.058 0.032

Age, sex, education, employment, marital status, psychiatric first-degree family history, alcohol use status, and smoking status were adjusted. Adjusted p-values with Bonferroni’s correction were calculated by multiplying raw p-values by the total number of multiple testing subscales.

* p<0.05;

** p<0.01;

*** p<0.001.

CTQ, Childhood Trauma Questionnaire-Short Form; BIS, behavioral inhibition system; BAS, behavioral approach system

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