Emergency. 2017; 5 (1): e17 OR I G I N A L RE S E A RC H The Prevalence of Personality Disorders among Emer- gency Nurses Based on MMPI-2 Questionnaire; a Cross- sectional Study Parvin Kashani1, Sahar Mirbaha2∗, Mohammad Mehdi Forouzanfar2, Farahnaz Meschi3, Alireza Baratloo2 1. Department of Emergency Medicine, Loghmane Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3. Department of Clinical Psychology, Karaj Branch Islamic Azad University, Alborz, Iran. Received: May 2016; Accepted: July 2016; Published online: 9 January 2017 Abstract: Introduction: The prevalence of behavioral disorders is substantially higher in stressful working environments such as emergency departments. The present study aimed to evaluate the prevalence of personality disorders among emergency nurses. Methods: In the present epidemiologic study, the prevalence of personality disor- ders among emergency nurses of three educational hospitals, Tehran, Iran, were evaluated based on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) test. After the questionnaires were filled, data were entered to a special software for MMPI-2 test and the final result was interpreted based on the opinion of a clinical psychol- ogist. Findings were reported using descriptive statistics. Results: 102 emergency nurses with the mean age of 30.2 ± 5.6 years were enrolled (100% female; 100% with master’s degree in nursing). The mean working time and experience of studied nurses were 210.8 ± 47.9 hours/month (130-370) and 4.1 ± 3.6 years (1-20), respectively. 32 (31.4%) cases showed symptoms of personality disorders The most common personality disorder detected in this study was somatization with 8.8%, hysteria with 6.9% prevalence, and pollyannaish with 4.9%. Among the studied factors only recent history of unpleasant event has significant correlation with existence of personality disorders (p = 0.015). Conclusion: The present study showed that somatization, hysteria, and pollyannaish were the most common personality disorders among the emergency nurses. History of an unpleasant event in the past year was the only effective factor in existence of personality disorders in the studied nurses. Keywords: Personality disorders; burnout, professional; workplace; nurses; emergency department © Copyright (2017) Shahid Beheshti University of Medical Sciences Cite this article as: Kashani P, Mirbaha S, Forouzanfar M, Meschi F, Baratloo A. The Prevalence of Personality Disorders among Emergency Nurses Based on MMPI-2 Questionnaire; a Cross-sectional Study. Emergency. 2017; 5 (1): e17. 1. Introduction Workplace stress is one of the most important causes of mental illnesses as statistics show that one fourth of the employed population have experienced some kind of job- related behavioral disorder (1). The prevalence of these behavioral disorders is substantially higher in stressful working environments such as emergency departments (ED). The medical staff, especially nurses and physicians, are at risk of physical and mental damage in ED due to the ∗Corresponding Author: Sahar Mirbaha; Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: +989121549505; Email: mirsa317@yahoo.com nature of their work, which involves high work load, long working shifts with insufficient number of personnel, lack of social support, lack of free time for resting, and encoun- tering serious injuries, wounds and adverse scenes (2). A systematic review in the past year has shown the 26-35% prevalence of personality and mental disorders among ED nurses due to their job (3, 4). These disorders not only affect the personnel’s health, but also decrease their efficiency and the quality of services they provide (5). Meanwhile, the proper performance of hospital department personnel plays a major role in decreasing the burden caused by accidents and diseases, and increasing patient satisfaction (6, 7). Existing studies have demonstrated the effect of job burnout on prevalence of behavioral disorders. However, findings reveal that in the same workplace environment, This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com P. Kashani et al. 2 people are not affected by job burnout and personality disorders equally. In other words, personal, family-related and social factors all exert an effect on the prevalence of these disorders (8, 9). Therefore, personality disorder is a multi-factorial condition, in which workplace stress, job burnout, and personal and social factors should be studied simultaneously. Although numerous studies are available in the field of personality disorders caused by workplace stress, scarcity of such information in Iran reveals the need for a study in this field. Therefore, the present study was designed aiming to evaluate the prevalence of personality disorders among emergency nurses. 2. Methods 2.1. Study design and setting The present study is a cross-sectional one, in which nurses working in emergency departments of 3 hospitals, Shoha- daye Tajrish, Imam Hossein and Loghmane Hakim, Tehran, Iran, were questioned in 2015. Before asking the questions, written informed consent was obtained from all the nurses. The researchers adhered to the principles of Helsinki Decla- ration throughout the study. 2.2. Participants The study population consisted of emergency nurses of the three mentioned educational hospitals. Not giving consent and not filling out the questionnaire correctly and the ques- tionnaire being invalid based on Minnesota Multiphasic Per- sonality Inventory-2 (MMPI-2) test were considered as exclu- sion criteria. Nurses were selected for questioning using sim- ple random sampling. A list of nurses working at the hospi- tals was prepared for this purpose and participants were se- lected randomly. 2.3. Data gathering Personality disorders were evaluated based on the standard MMPI-2 test. MMPI-2 is a standard questionnaire for gather- ing a wide range of self-described characteristics and scoring them, which is a quantitative index of the individual’s emo- tional adaptability and shows their attitude toward taking part in the test (10). MMPI test is the most famous and widely used personality questionnaire that has been developed as an objective tool for diagnosis of mental diseases. This test is a self-evaluation questionnaire with “yes” or “no” answers and has 3 validity scales and 10 clinical scales. Validity scales provide information regarding the subject’s approach to the test, while the 10 primary clinical scales are used for diagno- sis of mental disorders. The most valuable use of MMPI-2 is in screening abnormal people generally and determining the severity of the problem specifically (11). Diagnostic lay- ers and scales of MMPI-2 include hypochondriasis, depres- sion, hysteria, psychopathic deviate, masculinity/femininity, paranoia, psychasthenia, schizophrenia, hypomania, and so- cial introversion. To increase the clinical benefit of MMPI, 3 validity scales are present including lie detection scale, infre- quency, and defensiveness as correction or inhibition scale. Demographic data and MMPI-2 test were included in a ques- tionnaire, which was given to the studied nurses. 2.4. Definitions Recent unpleasant event was defined as any shocking tragic event during the previous year and recent trauma history was defined as any motor vehicle collision during the last year. 2.5. Statistical Analysis After the questionnaires were filled, data were entered to a special software for MMPI-2 test and the final result was interpreted based on the opinion of a clinical psychologist. Data were analyzed via STATA 11.0 statistical software and presented as mean ± standard deviation or frequency and percentage. 3. Results: 104 emergency nurses were questioned, 2 cases were ex- cluded due to unreliable questionnaires. Finally, 102 partic- ipants with the mean age of 30.2 ± 5.6 years (23-49) were enrolled for analysis (100% female; 100% with master’s de- gree in nursing). 1 (1%) case had positive family history of known psychiatric disease. Table 1 presents baseline char- acteristics of the studied cases. 52.9% of cases were mar- ried, 59.8% had stable employment status, 82.4% had vari- able work shifts, 71.4% earned ≥ 500 US dollars each month, 85.3% did not have any medical history, 86.3% did not have drug history, 33.3% had history of recent unpleasant event, and 4.9% had recent history of trauma. The mean work- ing time and experience of the studied nurses were 210.8 ± 47.9 hours/month (130-370) and 4.1 ± 3.6 years (1-20), re- spectively. 32 (31.4%) cases showed symptoms of personality disorders based on MMPI-2 interpretations. Table 2 shows the frequency of personality disorders among studied partic- ipants. The most common personality disorders detected in this study were somatization with 8.8%, hysteria with 6.9% prevalence, and pollyannaish with 4.9%. Table 3 shows the relationship of demographic and baseline variables with per- sonality disorders. Among the mentioned factors, only recent history of unpleasant event had significant correlation with existence of personality disorders (p = 0.015). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2017; 5 (1): e17 Table 1: Baseline characteristics of the questioned participants Variable Number (%) Marital status Married 54 (52.9) Single 47 (46.1) Divorced 1 (1) Employment status Stable 61 (59.8) Unstable 41 (40.2) Work shift Day 7 (6.9) Night 11 (10.8) Variable 84 (82.4) Income (US Dollar/month) <500 29 (28.4) ≥500 73 (71.4) Sole breadwinner Yes 6 (5.9) No 96 (94.1) Medical history Yes 15 (14.7) No 87 (85.3) Drug history Yes 14 (13.7) No 88 (86.3) Recent history of trauma Yes 5 (4.9) No 97 (95.1) Recent history of unpleasant event Yes 34 (33.3) No 68 (66.7) Table 2: Frequency of detected personality disorders among stud- ied emergency nurses based on MMPI-2 questionnaire Disorders Number (%) Somatization 9 (8.8) Hysteria 7 (6.9) Pollyannaish 5 (4.9) Depression 3 (2.9) Reactive Depression 2 (2.0) Schizopora 2 (2.0) Hypochondriasis 2 (2.0) Shy 1 (1.0) Anxiety 1 (1.0) 4. Discussion: The present study showed that somatization, hysteria, and pollyannaish were the most common personality disorders among the studied nurses. History of recent unpleasant event in the past year was the only effective factor in ex- istence of personality disorders in the studied nurses. The prevalence of personality disorders in the general population has been reported to be 4.4 - 10% (12-14). However, the rate is much higher among the participants of this study (31.4%). It should not be overlooked that some personality disorders re- main hidden and symptoms only show when the individual is under workplace stress. Mealer et al. reported 18% more anxiety and 11% higher depression rates in intensive care unit (ICU) nurses compared to the general population (29% more in total) (15). In the present study, prevalence of anx- iety and depression were 1% and 4.9%, respectively. In this study, nurses were selected from emergency departments. Exposure of the nurses to death scenes and dying patients for a long time can take a toll on their mental wellbeing (15). This is backed up by the findings of a study that showed emo- tional responses and psychophysiologic outcomes are more severe in nurses who have witnessed death and serious in- juries in comparison with others and therefore, individuals in this group are more prone to post-traumatic stress disor- ders (16). In contrast, Escriba-Aguir et al. showed that there is no evidence that workplace and workload negatively im- pact presentation of burnout syndrome (2). However, Yong et al. measured saliva cortisol and expressed that ED nurses have higher stress levels compared to nurses from other de- partments. They concluded that ED nurses are under more stress but this does not increase the risk of having mental dis- eases (17). In other words, ED nurses’ ability to adapt to stress might have prevented them from developing personality dis- orders and showing symptoms. Psychological resilience is a factor affecting mental disorders (15). Presence of psy- chological resilience results in a significant decrease in the prevalence of post-traumatic stress disorder, burnout syn- drome and symptoms of depression and anxiety. Therefore, resilience is a defense mechanism that can increase the abil- ity of the nurses and other medical staff to adapt to workplace stresses. Since this mechanism is acquisitive, training pro- grams to upgrade the skills of the treatment staff regarding psychological resilience can decrease the symptoms of men- tal and personality disorders, and increase job satisfaction (15). Environmental stressors are among the factors lead- ing to mental and personality disorders (18, 19). The find- ings of this study also showed that history of recent unpleas- ant event in the past year is an independent factor that exerts an effect on the existence of personality disorders in nurses. Nevertheless, to reach a conclusion in this regard, more stud- ies with proper design are needed. One of the limitations of this study was its low sample size, which may influence the power of the study. The nature of evaluating personality dis- orders is another limitation of this study. In most cases, per- sonality disorders are not a single problem and several diag- noses are made for an individual. Therefore, it is possible that the reported percentages are different from reality to some extent. In addition, the psychologist who makes the diagno- sis also plays a role. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com P. Kashani et al. 4 Table 3: The relationship of baseline characteristics of the studied population with personality disorders Variable Personality disorders P Value Absent Present Age (year) 30.1 ± 5.6 30.4 ± 5.7 0.808 Mean working (hours/month) 212.8 ± 51.8 206.6 ± 38.4 0.122 Mean working experience (years) 4.0 ± 3.4 4.3 ± 4.1 0.234 Marital status Single 31 (44.3) 16 (50) 0.709 Married 38 (54.3) 16 (50) Divorced 1 (1.4) 0 (0) Employment status Unstable 10 (19.6) 5 (20) 0.597 Stable 41 (80.4) 20 (80) Working shift type Day 4 (5.7) 3 (9.4) 0.720 Night 7 (10) 4 (12.5) Variable 59 (84.3) 25 (78.1) Income (US Dollars/month) < 500 19 (27.1) 10 (31.3) 0.420 ≥ 500 51 (72.9) 22 (68.8) Sole breadwinner No 64 (91.4) 32 (100) 0.097 Yes 6 (8.6) 0 (0) Medical history No 61 (87.1) 26 (81.3) 0.309 Yes 9 (12.9) 6 (18.8) Drug history No 62 (88.6) 26 (81.3) 0.242 Yes 8 (11.4) 6 (18.8) Recent history of unpleasant event No 52 (74.3) 16 (50) 0.015 Yes 18 (25.7) 16 (50) Recent history of trauma No 68 (97.1) 29 (90.6) 0.176 Yes 2 (2.9) 3 (9.4) Data were presented as mean ± standard deviation or number and percentage. 5. Conclusion: The present study showed that somatization, hysteria, and pollyannaish were the most common personality disorders among the emergency nurses. History of a recent unpleasant event in the past year was the only effective factor in exis- tence of personality disorder in the studied nurses. 6. Appendix 6.1. Acknowledgements We would like to express our special thanks to Ms. Mahnaz Nikpeyma who kindly helped us in performing this study. 6.2. Authors contribution All the authors have contributed to drafting/revising the manuscript, study concept, or design, as well as data collec- tion and interpretation. 6.3. Conflict of interest All authors declare that there is no conflict of interest in this study. 6.4. Funding This study was conducted with a grant from the Clinical Re- search Development Center of Loghmane Hakim Hospital. This study was a part of Dr. Sahar Mirbaha’s thesis for Emer- gency Medicine Residency at Shahid Beheshti University of Medical Sciences, Tehran, Iran. 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