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As a psychodynamic therapist, I have spent much of my career studying and treating personality disorders, particularly borderline personality disorder. Yet in recent years, another topic has increasingly captured my attention: mood temperament.
Much of the credit belongs to my friend and colleague, psychiatrist Nassir Ghaemi of Tufts University and Harvard Medical School. Through our many conversations about mood disorders, bipolar illness, and psychiatric diagnosis, he introduced me to a concept that receives surprisingly little attention in contemporary psychiatry and psychotherapy: hyperthymic temperament.
Most mental health professionals are familiar with depression and mania. Far fewer are familiar with the idea that some people possess enduring, biologically based mood styles that exist between health and illness. These affective temperaments were first described by Emil Kraepelin more than a century ago and later elaborated by Hagop Akiskal and his colleagues. They include depressive, cyclothymic, irritable, anxious, and hyperthymic temperaments. In fact, up to 20 percent of the general population has a marked affective temperament (Rihmer et al., 2010).
Hyperthymic temperament is perhaps the most intriguing of this group.
Individuals with hyperthymia tend to be energetic, optimistic, confident, productive, socially outgoing, and enthusiastic about life. They often require less sleep than average (often around six hours per night), possess considerable stamina, and seem perpetually driven toward new projects and experiences. Many are charismatic and highly successful. Some of history’s most accomplished leaders, entrepreneurs, and innovators may well have possessed hyperthymic traits (Ghaemi, 2011).
Distinct From Mania
Importantly, hyperthymia is not the same thing as mania. Hyperthymic individuals are not necessarily ill. Rather, they occupy a position on the affective spectrum between euthymia (normal mood) and hypomania. Their elevated energy and confidence are stable traits rather than episodic symptoms.
Yet despite a substantial body of research, hyperthymic temperament is absent from the Diagnostic and Statistical Manual of Mental Disorders (DSM). While the DSM includes a number of personality disorders and symptom-based syndromes, it has made little room for enduring affective temperaments. As a result, many clinicians receive relatively little training in recognizing them. Some have never heard of them.
This relative neglect may contribute to diagnostic confusion. In a forthcoming paper with Alex M. Ray in Psychodynamic Psychiatry, we explore the possibility that hyperthymic temperament is sometimes mistaken for narcissistic personality disorder (Ruffalo and Ray, in press).
At first glance, this confusion is understandable. Both hyperthymic and narcissistic individuals may appear highly self-confident. Both may be ambitious, socially assertive, and willing to take risks. Both may enjoy attention, crave stimulation, and possess a strong sense of personal capability. There are, however, important differences.
Differences Between Hyperthymia and Narcissistic Personality
Narcissistic personality is generally understood as a disorder of personality functioning involving vulnerabilities in self-esteem regulation, chronic interpersonal difficulties, and reliance on defensive forms of grandiosity. The confidence of narcissistic individuals is more fragile than it may appear and depends heavily on admiration from others.
Hyperthymic confidence, in contrast, emerges from a biologically rooted mood style characterized by high energy, optimism, and activation. Hyperthymic individuals typically display other mood-spectrum features as well, including reduced need for sleep, increased productivity, heightened sociability, high libido, and increased physical and mental energy. Sometimes they can be impulsive. Their self-confidence is often accompanied by stable relationships, consistent occupational functioning, and an absence of the severe interpersonal dysfunction commonly associated with personality pathology.
In other words, not every confident person is narcissistic. In fact, narcissistic patients lack self-confidence and seek to compensate for it defensively.
This point may seem obvious, but we live in a cultural moment in which the label “narcissist” is applied with remarkable frequency. Popular discussions often equate self-confidence, ambition, or charisma with pathological narcissism (Staal & Ruffalo, 2026). Such assumptions can obscure important differences between temperament, personality style, and psychiatric illness.
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Mood Temperaments
Mood temperament occupies a middle ground between normal personality and major psychiatric illness. It helps explain why some people seem naturally optimistic while others are chronically melancholic, and why some thrive on stimulation while others seek predictability and routine. These temperaments are genetically and biologically related to manic-depressive illness; they run in families with depression and bipolar disorder.
For clinicians, greater awareness of hyperthymia may improve diagnostic accuracy and inform treatment. For patients, it may provide a more nuanced understanding of longstanding patterns of behavior.
While most hyperthymic patients do not require treatment, hyperthymia does predispose to major mood episodes (Rihmer et al., 2010), and sometimes hyperthymic patients can get into trouble due to their impulsivity. Low-dose lithium has been proposed as an effective treatment strategy.
Although temperament played a central role in classical psychiatry, it unfortunately receives relatively little attention in contemporary psychiatric nosology. Greater consideration of these enduring affective styles may enrich our understanding of both personality and mood disorders and help bridge the gap between biological and psychodynamic traditions.
