Enduring personality changes in patients living at home and challenges for community nursing

Introduction: Personality and behaviour disorders include enduring personality changes which cannot be attributed to brain injury or disease. Traumatic experiences can cause personality vulnerability. The research aimed to determine the characteristic enduring personality changes, the risk factors and the quality of life of patients living in their home environment. Methods: The field research is based on a quantitative method. The data were gathered through a structured questionnaire. The sample consisted n = 606 of patients (18.56 %) from the Central Slovenia region, aged between 20 and 92 years. The data were processed using descriptive statistics, the χ2 test, group classification and discriminant analysis. Results: The enduring personality changes are present in 9 % (n = 53) of the patients who tend to be older, with lesser educational attainment. Only a quarter of the enduring personality changes patients (n = 10) are receiving psychiatric treatment. Among the groups of patients with or without enduring personality changes statistically significant differences have been observed in relation to their past experiences with a traumatic event (p < 0.001), level of independence in the performance of the activities of daily living (p < 0.001), incidence rate of chronic pain (p = 0.002), social integration (p = 0.016), suicidal thoughts (p < 0.001) and incidence rate of comorbidity of somatic illnesses and psychological disorders (p < 0.001). Discussion and conclusion: Results of the study point to the share of enduring personality changes patients living at home in which the condition remains largely unrecognized, untreated and shadowed by other mental and physical health issues. Community nurses play a crucial role in timely recognition and detection of the changes and the patients' referral to multidisciplinary treatment. A national research project conducted by community nurses is needed to highlight the prevalence, treatment and good practice in the delivery of pertinent services.


Introduction
The World Health Organisation (WHO) constitution states that there is no health without mental health (Promoting Mental Health, 2005).Mental health is a state of well-being in which individuals realize their own intellectual and emotional abilities, can work productively and are able to feel and function well, be resilient in the face of life's challenges and make a contribution to their community (Jeriček Klanšček, et al., 2010;Resolucija o nacionalnem programu duševnega zdravja, 2011).Globally, mental disorders are one of the ten most common causes of functional limitations with severe social and economic ramifications (Resolucija o nacionalnem programu duševnega zdravja, 2011).It is estimated that 450 million of people out of the total population suffer from some type of mental disorder and that one in three persons experiences this problem at least once in a lifetime (Dernovšek & Šprah, 2008).The most common reasons for seeking first medical help on the primary level of health care in Slovenia and other European countries are depression, anxiety disorders, acute stress reaction and adjustment disorders (Jeriček Klanšček, et al., 2010).Compromised mental health may have detrimental effect on chronic diseases, rehabilitation and increase the demand for medical services (Annells, et al., 2011).Enduring personality changes (EPC) are defined as severe disturbances in the personality and behavioural tendencies of the individual; not directly resulting from disease, damage, or other insult to the brain, or from another psychiatric disorder.
The experience of traumatic events in childhood is associated with long-term health effects.Early exposure to traumatic stress, in the form of abuse or neglect, presents a major risk factor for a cascade of neurobiological reactions leading to permanent changes in brain development, later psychopathology and behavioural disorders (Teicher, et al., 2002;Teicher, et al., 2006) as well as compromised physical health.Experiences of traumatic events in childhood have been shown to have long-term consequences for health in adulthood (Mulvihill, 2005).Schore (2002) reports that 60 % of men and 50 % of women experience a traumatic event at some point in their lives.The experience of trauma can often result in a wide range of psychosocial and psychiatric disturbances and complex psychiatric comorbidity.It has been shown that the prevalence of suicide attempts, suicidal behaviour, suicidal ideation and increased morbidity is elevated among people who have experienced traumatic events (Krysinska, et al., 2009).The study conducted in Slovenia by Sedmak and colleagues (2006) established that 23.7 % out of the 1006 respondents had experienced family abuse and violence, of which 73 % happened in their childhood.Selič and colleagues (2008) report that 30 % of the population studied (509 patients in the Republic of Slovenia) confirmed their past experience with both physical and psychological violence and abuse.Bronisch (1996Bronisch ( , cited in Židanik, 2003) ) claims that one third of the persons that completed suicide had suffered from some type of personality disorder.Traumatic experience can cause personality vulnerabilities with cognitive, emotional and behavioural problems which are manifested as a hostile or mistrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being 'on edge', as if constantly threatened, and estrangement (The ICD-10 classification of mental and behavioural disorders, 1992;1993;Maddern, 2004;Mulvihill, 2005;Adams, 2006;Daud, et al., 2008;Karner, 2008;Beltran, et al., 2009;Seides, 2010).Personality disorders are very common and present one of the greatest challenges in the field of health care (Židanik, 2003), and remain one of the least explained psychiatric categories (Benedik, 2004).
The literature review reveals that the nature and the incidence of EPC in the Republic of Slovenia and abroad has not been the object of direct investigation.EPC may present a special problem in community nursing as they may hinder or interfere with the process of nursing care, the treatment, rehabilitation and social integration of patients (Annells, et al., 2011).

Aims and objectives
The aim of the study was to establish the nature and the incidence of EPC as well as their impact on the quality of life of the affected individuals, their social relations and social integration.
Based on theoretical rationale, seven hypotheses were proposed: H1: At least one fourth of the adult patients cared for by community nurses in their homes are diagnosed with EPC.
H2: There is a statistically significantly higher prevalence of EPC in patients with a history of traumatic victimisation as compared to those without this experience.
H3: There are statistically significant differences in the level of dependence in the performance of daily living activities between patients with EPC and those without EPC.
H4: There is a statistically significantly higher incidence of EPC in patients experiencing chronic pain as compared to those without this symptom.
H5: There are statistically significant differences in social functioning (social inclusion, society memberships) between patients with EPC and those without EPC.
H6: There are statistically significantly higher suicidal tendencies in patients with EPC as compared to those without EPC.
H7: There is a statistically significantly higher incidence of comorbid psychological and physical disorders in patients with EPC as compared to those without EPC.

Methods
The field research conducted is based on a nonexperimental quantitative method.

The description of the research instrument
The questionnaire was developed on the basis of specific EPC criteria, not attributable to brain damage and disease (The ICD-10 classification of mental and behavioural disorders, 1992; 1993), publications on personality disorders (Benedik, 2004), EPC (Leeuw, et al., 2005;Daud, et al., 2008), social relations and interactions (Kobentar, 2003), and a standardised detailed assessment of posttraumatic stress (Briere, 2001).The survey was conducted via a written structured questionnaire including 20 questions (openended, closed-ended and half-closed-ended questions).The survey used dichotomous and multiple-choice questions where the respondents selected an answer from a list of choices.In some instances the respondents evaluated the statements on a Likert 5 point frequency scale where the number one indicated the absence of opinion/behaviour and the number 5 the enduring presence or strongly expressed.Prior to performance of a full-scale research project, a preliminary pilot study was carried out on 30 members of the relevant population in order to evaluate the content and comprehensibility of the questions, and accompanying instructions.The Cronbach alpha coefficient (α = 0.7) showed appropriate internal consistency for each statement (social relations, personal characteristics/ personality vulnerability, impact of health status on work/home/relations and activities of daily living), and the reliability of a psychometric instrument.

Description of a sample
Data were collected on a cohort of adult community nursing service users from the Central Slovenia region., 2012).Included in the study were the patients over 18 years of age, living in their home environment who were visited by community nurses on the day the study was conducted.The participation was voluntary.The total of 820 questionnaires was distributed, among which 38 were invalid.The final sample included 606 participants of whom 182 were men (30 %) and 423 were women (70 %), aged from 20 to 92 years (mean age 62 years; s x = 17.8).Most of the respondents n = 181 (30 %) belonged to the age group from 66 to 80 years and 171 (28 %) were aged between 51 to 65 years.Most of the respondents n = 195 (32 %) completed a 4-year secondary education and 149 (25 %) of the participants had earned higher professional or university degrees.Half of the participants n = 302 live in urban areas, 195 (32 %) in the suburbs, and 108 (18 %) in the village.Nearly half of the respondents n = 291(48%) are married and 128 (21 %) are widowed.Most of the respondents n = 220 (36 %) share their lives with their spouse or a partner, 134 (22 %) participants live by themselves, 123 (20 %) participants live with their spouse or partner and relatives, and 115 (19 %) of them live with their relatives.Only 13 (2 %) respondents share their living facility with their roommates.

The description of the research procedure and data analysis
Prior to questionnaire distribution, an ethics approval of research was granted by the Republic of Slovenia National Medical Ethical Committee (No. 92, August 24, 2012) and a permission of the Community Health Centre was obtained to carry out the survey among the patients for the purposes of Master thesis research (No. 511, August 10, 2012).
The invited respondents were informed of confidentiality and anonymity protection, the intended use of the data collected as well as of the possibility to decline their participation.A written informed consent was prospectively obtained from the addressees as to their voluntary participation.Detailed written instructions were provided along with the questionnaire on how to fill out the questionnaire.The questionnaires and the stamped envelopes with return post address were distributed to patients after the preventive and/or curative nursing services had been delivered.The respondents returned the completed questionnaires in closed envelopes to the community nurses within an agreed period of time.Community nurses collected the file folders within the agreed period of time at community nursing administrative bases.The survey was conducted from September 10, 2012 until December 14, 2012.
Multivariate method of discriminant analysis was used to discriminate between the two groups of respondents in terms of independent performance of the activities of daily living, social relations, suicidal thoughts and additional disorders (or diseases) co-occurring with the primary disease.The discriminant analysis was used to explore the relationship between the descriptive (dependent) variable and independent numerical variables.To determine the differences between the respondents with or without EPC as regards the necessity of psychiatric treatment, the Kullback 2Î test (likelihood ratio) was used as an alternative to χ 2 test for which the necessary conditions were not given (Field, 2006).A 5 % difference and a p < 0.05 were considered to be statistically significant.For the statistical analysis, the Statistical Package for the Social Sciences version 18.0 (SPSS Inc., Chicago, IL) was utilised.
The basic statistical parameters of descriptive statistics were calculated for each variable.Hierarchical cluster analysis was employed in grouping the respondents in regards to the presence of EPC.Ward's method was used to determine the distance between the clusters.
The Squared Euclidean distance was applied as a measure of distance between the variables which were standardised before grouping.

Results
Results of the study show that 91 % of the respondents do not suffer from EPC and the rest (9 %) are inflicted by the disease.A high majority of the respondents (91.8 %) were properly classified.There is a statistically significant difference between the two groups in relation to the respondents' age (χ 2 = 12.504, p = 0.014) and education (χ 2 = 23.950,p < 0.001).Enduring personality changes are present in 62 % of the respondents aged over 65 years, with complete or incomplete primary education (43 %).
Among respondents with the experience of at least one traumatic event (64 %), 13 % suffer from EPC.In the respondents with no history of trauma, EPC was identified in 3 %.There are statistically significant differences (χ 2 = 9.304, p = 0.002) regarding the gender of people exposed to a traumatic event, 74 % were male and 61 % female.The chi-squared value (χ 2 ) is 14.589 and is statistically significant.It can be concluded that traumatic experience is a determining factor in the development of EPC.A history with violence, abuse and neglect in their childhood was confirmed by 20 % of the respondents.
The patients with EPC have more difficulties to independently perform the activities of daily living and the differences between the groups are statistically significant.Gender-wise, no statistically significant differences in this respect were observed between male and female respondents (dressing, undressing: t = -0.121,p = 0.904; lying/sitting down and getting out of a bed or chair: t = 0.964, p = 0.336; taking a bath or a shower: t = 0.858, p = 0.391; walking, mobility: t = 0.721, p = 0.471) (Table 1).
Differences were established between the groups in regards to the presence of chronic pain.Of the respondents suffering from chronic pain (pain in the neck, lower back, headache, migraine, pain in the joints), 11 % present with EPC and only 3 % of those without chronic pain.The chi-squared value χ 2 = 10.000 and is statistically significant (p = 0.002).It can be concluded that there is a correlation between chronic pain and the presence of EPC.
Nine out of the twelve variables (75 %) concerning problems in social functioning and performance were identified to be statistically significantly related to EPC.The social relations of patients with EPC are less frequent as compared to those without this condition (Table 2).
The variable 'I think it would be better if I were dead or that I intentionally and seriously harmed myself ' has a statistically significant impact on group differentiation (Wilks λ = 0.861, p < 0.001).

Discussion
The first hypothesis proposing that EPC are present in at least one quarter of the respondents was not confirmed.It was determined that EPC, classified as personality disorders of the advanced age, are present in only 10 % of the respondents.The study produced results which corroborate the findings of Marlowe and Sugerman (cited in Židanik, 2003) suggesting a 2 % -13 % incidence of EPC among the general population.In contrast, Kaplan (cited in Židanik, 2003) found the EPC incidence ranged from 15.5 % to 32 % EPC.Židanik (2003) reported a high percentage of people with potential personality disorders (41.2 %) in Maribor region.Community epidemiological surveys estimate that as many as 25 % of the adult population in the United States meet the criteria for mental disorder (Kessler, et al., 2005) and that one family out of five is inflicted with a mental disease (Medline Plus, 2009).The present study shows that the respondents with EPC are generally older, which could also be attributed to the fact that the sample included a high percentage of older adults with relatively low levels of education.
EPC along with lower educational achievement and aging may complicate the nursing process and interfere with social relations, learning of social skills and cognitive behavioural therapy techniques (Magoteaux & Bonnivier, 2009).Results of the study confirmed the hypothesis that the respondents without EPC maintain better social relations compared to those who suffer from this condition.This fact can be explained by the personal vulnerability of EPC patients whose inflexible and maladaptive behaviour leads to impairment in their interpersonal, social, and occupational functioning (The ICD-10 classification of mental and behavioural disorders, 1992).As a consequence, stigmatisation and discrimination create and further reinforce their social isolation (Resolucija o nacionalnem programu duševnega zdravja, 2011).Experts observe that mental status may be associated with increased rates of somatic complaints and general medical conditions, and vice versa.Patients with chronic diseases often develop other comorbid psychiatric conditions, depression being the most common (Annells, et al., 2011; Inštitut za varovanje zdravja Republike Slovenije, 2010).Elderly  adults with a history of traumatic event are at a greater risk to develop chronic diseases, compromised physical functioning.gastritis, angina pectoris and arthritis (Pietrzak, et al., 2012).A good half of the respondents in the current study reported having problems with neck and back pain, and a quarter of them presented with headache and migraines.Our results are comparable to the findings of Lew and colleagues (2009) which confirm that the most common chronic pain locations were the back and head.The data gathered support the hypothesis that the patients with chronic pain score higher on a measure of EPC than the respondents without chronic pain.The result is not surprising as chronic pain augments a person's suffering and personal vulnerability (Ščavničar, 2004).Literature review conducted by several researchers confirmed the detrimental effects of fragile mental health on the development of chronic diseases.Poor mental health also hinders medical rehabilitation process and increases the demand for medical services (Annells, et al., 2011).The following hypothesis tested whether EPC more commonly cooccur with other health issues than in the respondents without EPC.The results confirmed the hypothesis that the average incidence of comorbidity is more common in patients with EPC than in those without them.The differences among genders are statistically significant.Women reported higher rates of several physical health conditions than men.The hypothesis that suicidal ideation is more frequent in patients with EPC than in other respondents was confirmed.This finding is very important, especially in view of the data retrieved by retrospective studies which observe that one out of three suicide victims had some type of EPC (Židanik, 2003).A history of traumatic event was reported by a significant majority of the male (75 %) and a good half of female study participants.The findings of the current study accord with the earlier observations (Schore, 2002) which suggest that 60 % of men and 50 % of women have experienced some traumatic event.
A little less than 50 % of the respondents reported a history of catastrophic/traumatic experience involving a serious injury, experience of coercive behaviour, life-threatening situations or seeing another person injured or killed.One fifth of the respondents reported experiencing traumatic life events, such as violence, psychological, physical and/or sexual abuse and neglect.These results accord with the findings of the public opinion research on family violence (Sedmak, et al., 2006), which was conducted on a representative sample of 1006 adult Slovenian citizens.The evidence gathered is in agreement with the hypothesis that EPC are more common in individuals with a history of traumatic event (The ICD-10 classification of mental and behavioural disorders, 1992).There is an association between prolonged traumatization and personality impairments, psychopathology and lifelong maladaptive behaviours.Prolonged torture experiences or extreme early trauma exposure is reflected in impaired personality formation which enhances the development of cognitive, affective and behavioural vulnerabilities (Daud, et al., 2008;Rick & Douglas, 2007).Mulvihill (2005) documented a strong relationship between childhood trauma and psychological difficulties and physical illness in later life.
The results produced by the current study corroborate these findings.In the performance of the activities of daily living, the respondents with EPC need most assistance with walking or movability while they are more independent in other activities, i.e. dressing and undressing.A little less than one fifth of the respondents need help and support of another person or assistive devices, some of them had their homes adapted to suit their changing needs.The hypothesis that there are statistically significant differences in the level of independence between patients with and without EPC was confirmed.This finding could be also attributable to the fact that the sample involved a large proportion of the elderly adults.A good half of the respondents seek medical care of general practitioners and more than one third of family doctors and various specialists.
A surprisingly small number of patients with EPC (25 %) are treated by psychiatrists.This finding leans towards a conclusion that EPC in the study participants often remain unrecognised, untreated and hidden behind other mental diseases and physical conditions, which accords with the results of the literature review (Židanik, 2003;Benedik, 2004, Magoteaux & Bonnivier, 2009).The scarcity of psychiatric treatment may be explained in part by the EPC sufferers' considerable personal distress and social disruption, disabling them to seek appropriate medical help.In light of the above research, community nurses play a crucial role in recognizing a personality disorder, and provide the adequate treatment based on partnership and mutual trust, the necessary support and health education of patients and their families (Maddern, 2004;McAllister, 2010;Annells, et al., 2011).
The current study and the literature review results indicate that EPC patients share certain clusters of traits: late adulthood (age 65 and beyond), low educational attainment (primary school), a history of traumatic event (four-fifths), the comorbidity of psychiatric disorders and physical conditions, chronic pains, suicidal ideation, difficulty in performing daily activities, poor social integration, weak social network and ties, low rate of psychiatric treatment (10 out of 53), non-recognition and absence of treatment of EPC symptoms which are hidden behind the decoys of other mental and physical disorders.
The findings of the study do not necessarily reflect the real number of occurrences of EPC among the residents of the Central Slovenia region.Caution must be applied in the interpretation of the data gathered which, however, provide a valuable insight into the health status of the population studied.The most worrisome are the responses concerning suicidal behaviour and social isolation.Though the results might not be transferable to the entire Slovenian population, they have important implications for the community nursing practice to timely detect and recognise the symptoms of EPC in patients cared for in their home settings.
Community nurses should have the knowledge, training and experience to refer the patients to multidisciplinary treatment and ensure the persons living with EPC the highest quality of life possible.Another issue emerging from these findings relates to the community nurses' responsibility to gain additional knowledge on personality and psychopathology, especially enduring personality changes, in order to offer appropriate care to this patient population.As several questions remain unanswered, further studies on the current topic are recommended on a national level.

Conclusion
As community nurses visit people in their own homes on a continuous basis, they are often the first care providers who can identify the healthcare needs of patients and families.A patient's positive experience of the first community nurse visit largely impacts the quality of therapeutic relationship and patient outcomes.The EPC patients' lack of control and their decreased judgement and insight into their situation impede the treatment process.Creating a relationship, which is central to nursing work, requires not just communication skills but therapeutic engagement, perseverance, patience and dialogue.It is also of importance that nurses recognise specific risk groups within their community in order to plan nursing interventions in their homes, improve service integration and patient access to primary care and specialist medical services.The nurse's role moves beyond an illness-care role to that of diminishing stigmatisation, discrimination and social exclusion of people diagnosed with mental disorders which adversely affect their quality of life.Nurses can improve the patients' sense of well-being in life by health promotion, timely recognition of the disease, psychosocial evaluation, referral, support and multidisciplinary approach to treatment and rehabilitation as well as social integration.
The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research, 1993.Geneva: World Health Organization.
The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines, 1992.Geneva: World Health Organization.
Cite as/Citirajte kot: Maček, B., Dernovšek, M.Z.& Kobentar, R., 2015.Enduring personality changes in patients living at home and challenges for community nursing.Obzornik zdravstvene nege, 49(4), pp.270-283. http://dx.doi.org/10.14528/snr.2015.49.4.63 The services are organised by the Community Health Centre Ljubljana and provided by five organisational units: Health centre Ljubljana Bežigrad, Health centre Ljubljana Center, Health centre Ljubljana Moste-Polje, Health centre Ljubljana Šentvid, Health centre Ljubljana Šiška, Health centre Ljubljana Vič-Rudnik.The Community Health Centre covers the health care needs of 280.607 inhabitants of the City Municipality of Ljubljana, on the territory of 275 km 2 (Statistični urad Republike Slovenije, 2012).A purposive sample included 18.56 % of the statistical population (statistics of patient motion by the end of year 2011, with the total of 3265 patients treated) (Inštitut za varovanje zdravja Republike Slovenije