Structure of Personality at Intrapsychic and Interpersonal Levels and Depression of Caregivers of Patients Affected by Alzheimer ’ s Disease : Which Psychotherapeutic Approach ?

Background: Many studies have underlined as caregiving for people with Alzheimer’s disease (AD) is highly stressful and has significant negative consequences. Objectives: The study of the structure of personality, can help to understand the association between depression, intrapsychic and interpersonal processes of caregivers of Alzheimer’s disease patients and what kind of intervention can be planned to favor the stress burden management. Methods: Case group: Caregivers (CG) (n = 75); control group, Subjects not Caregivers (nCG) (n. 104). Tests: SASB questionnaire (Structural Analysis of Interpersonal Behavior) describing intrapsychic and interpersonal processes of the structure of personality validated on the basis of DSMIV; CDQ questionnaires—depression. Results: Intrapsychic level: From the results it emerged that CGs had lower autonomy in their choices, and lower acceptance of their own feelings, and exercised greater self-control exhausting themselves toward predetermined goals, and more depression compared to the control group. They may be not able to achieve psychic equilibrium in the presence of stress: they may likely become disoriented and engage in behaviors that may be self-defeating. SASB-Cl = Autonomy (p < 0.001); SASB-Cl2-Autonomy and Love (p < 0.001), SASB-CL3-Love (p < 0.001); SASB-Cl4 Love and conHow to cite this paper: Velia, G.M., Vespa, A., Berti, S., Gori, G., Ottaviani, M., Meloni, C., Fabbietti, P., Pelliccioni, G., Paciaroni, L. and Spatuzzi, R. (2018) Structure of Personality at Intrapsychic and Interpersonal Levels and Depression of Caregivers of Patients Affected by Alzheimer’s Disease: Which Psychotherapeutic Approach? Advances in Alzheimer’s Disease, 7, 103-118. https://doi.org/10.4236/aad.2018.74008 Received: September 7, 2018 Accepted: November 19, 2018 Published: November 22, 2018


Introduction
To assist a person with dementia it can wear out emotional resources and the caregiver can show anxious-depressive symptoms [1] with somatic troubles that often limit relief abilities [2] [3] [4] [5] [6].A progressive illness such as the Alzheimer's disease leads to a deep change in the life style of the whole family system.The changes imposed by the progression of illness pose different problems in the various stadiums from a practical and organizational and also emotional point of view.Caring for dementia sufferers is a highly demanding task both emotionally and physically [7].All of these aspects can activate new conflicts with tiredness, with economic problems or with decisions to take.They can also reactivate ancient tensions that sometimes lead to definitive breakups [8] [9] [10].
Behavioral and psychological symptoms of dementia (BPSD) affect the majority of patients at the same point in the progression of the disease [11] [12] [13] [14], involving the patient, the family caregiver and their environment.
BPSD are more stressful to caregivers than cognitive or functional decline, because they are felt as the most difficult to manage and have a negative impact on the relationships between the caregiver, patient and family [1] [14].
Moreover caregivers differ in their emotional responses to BPSD.The caregiver's perception of the patient's problems is more important than the problem linked to the patient's behavior "per se" [15] [16].The caregiver's interpretation reaction may be adequate or inadequate.So the subjective factors and individual differences among caregivers in the caring experience and in coping are fundamental [17].
The personality characteristics affect the processes that individuals use to appraise stressful events and predispose them to cope in certain ways when they confront these events [7] [17] [18].
Personality also has significant direct and indirect effects on mental health and direct effects on physical health.The objective and subjective burden of care and psychiatric morbidity [7] [17], such as depression, is associated with specific psychological characteristics of the caregiver [19] [20] [21], and influence some factors of the caregivers themselves, such as their coping strategies to deal with the symptoms and meaning of the illness [19] [20] [21].
Personality traits are an indicator of global individual propensity to experience negative influences.Individuals who show intrapsychic problematic dimensions tend to show behaviors such as "emotional imbalance, unrealistic ideas, desires and needs excessive or inappropriate coping responses", while those who are "calm, relaxed, resilient, secure, non-emotive, self-satisfied" [20] [21] [22] [23] may present better coping.Moreover caregiving is at high risk for social isolation [24] [25].
The tendency to isolation and low optimism are factors that facilitate depression [26].So the individual propensity to social interaction and activities is another important aspect.Caregiver's extraversion decreases both burden and depression.On the basis of all these considerations it could be useful that caregivers participate in groups of psychological support [27] [28] [29] [30] [31] that have the purpose of furnishing coping tools to decrease the levels of stress and to offer a support finalized to the acceptance of the illness, to the elaboration of the change of emotional reactions such as anxiety, sense of guilt, depression, anger, embarrassment and loneliness.Everything contributes to improving the quality of life of the whole family nucleus, to favour the permanence of the patient in his/her own domicile and to raise the awareness of the families of not being abandoned in this painful situation.The inclusion of caregivers' personality traits studies would increase the knowledge of their role and hopefully contribute to improve the quality of life of both caregiver and patient.The specific aim of our study was to establish whether a difference exists in the intrapsychic and interpersonal dynamics and in the prevalence of depression of caregiving and not caregiving subjects.The use of the SASB model in the present study contributes to the knowledge of intrapsychic and interpersonal processes in order to plan a more suitable psychotherapeutic intervention for the caregiver as part of multidisciplinary care.All the subjects studied (CG and nCG) were subdivided on the basis of the following independent variables: sex, age marriage status and educational level and were homogeneous for these variables: no significant differences emerged between the two samples (Table 1).

Sampling
All the patients were affected by Dementia of Alzheimer with clinical diagnosis through Tac.The diagnosis of Alzheimer Disease was effected respecting the criteria of the DSM-IV while its degenerative nature was identified following the standardized criterions NINCDS-ADRDA for the diagnosis of illness of Alzheimer [32].In particular all criteria were satisfied for the diagnosis of "probable Illness of Alzheimer" (with the exception of the liquorale examination).All the patients in this study showed level 6 of the Functional 6 Assessment Staying Test.
Inclusion criteria included an age greater than 45 years (adult 45 -59 yrs) and also elderly CG (60 -75 yrs).Exclusion criteria included: refusal to participate; inability to provide informed consent; previous history of depression; use of psychotropic drugs (all, including antidepressant).
One hundred and twenty three caregivers were approached in the clinic by the physician and asked to participate in the study.All participants signed a consent form regarding study protocol after detailed explanation by the physician at the day center for Alzheimer disease patients.
Only ninety caregivers decided to participate and to fill out and sign the consent form.The caregivers were free to complete the questionnaire either in the center or at home.
Subjects who decided to complete forms at home were given a self-addressed, stamped envelope to return the forms.Fifteen patients didn't answer all the questions in the questionnaires: it was therefore decided not to consider them for the analysis.All subjects (case and control groups), were asked to complete the following psychological and psychosocial questionnaires: 1) Social schedule, including data on gender, age, marital status, educational level, profession.3) CDQ tests by Cattell [35] have been used as methods of Self-report which describe depression, respectively.The range is subdivided as follows:

Statistical Analysis
The data were analyzed using SPSS 11.5 (SPSS Inc.Chicago, Illinois).Variance analysis (ANOVA) was applied to evaluate the differences between the two groups of subjects (case and control groups) on the Scales SASB and CDQ.
The maximum significant level considered in this study was 0.05.To achieve power of 0.80 and a medium effect size, a sample of 60 was required to detect a significant model.

SASB Questionnaire (Intrapsychic Behaviours) and CDQ
The results show a significant difference for the varying depression between the study group of caregivers and the control group of healthy people not assistant of family patients (p < 0.001).
In terms of intrapsychic modalities the two groups (caregivers (CG) and control group (nCG) obtained different scores in all clusters except SASB Cl 8 Hate and autonomy-self-negligent and mentally absent.Patients are not likely to neglect themselves and their needs.
Significant differences were found in the intrapsychic processes of SASB questionnaire (Figure 1) of the two groups CG and nCG in the following clusters:  Synthesizing caregivers are less prone to be in touch with their own feelings and emotions.They are not satisfied with themselves, their lives and their entourages and show difficulties to cope with stress.They don't always manifest self-appreciation and self-esteem and may not be able to achieve emotional and psychic equilibrium in the presence of stress.In addition they are less likely to protect themselves and to utilize crisis and stress for their own emotional development.
In presence of stress they may likely become disoriented and engage in behaviors that may be self-defeating and self-abusive.They show serious difficulties in facing and accepting their own emotions.The presence of self-criticism creates an additional problem.
Because of this poor coping they may be more subject to depression and depressive moods.
The profile of the SASB model shows high likelihood of depression in caregivers group.
Moreover these subjects display low assertiveness, and low ability to accept themselves and support themselves (to treat, care for, console and consolidate).
They may be oppressive towards themselves and may accuse themselves of inadequacy, evoking feelings of guilt and shame, which purport low self-esteem.In general, caregivers exercise greater self-control aimed to specific objectives, exhausting themselves toward predetermined goals compared to control group.
The results in Anint A questionnaire of SASB Model show that caregivers present a minor state of depression without reaching a level of major depression.

Interpersonal Behaviors
On the basis of these intrapsychic processes it is possible to describe the differ-Advances in Alzheimer's Disease More depression is correlated with less autonomy and love, and with more control.The caregivers' behaviors of not being spontaneous with self-acceptance and pleasure in their experience or being disoriented give little weight to problems and important choices in life is correlated with depression.The caregivers' behaviors of self-criticism and oppression and tendency to self-neglecting behaviours (of needs at emotional and physical levels) are correlated with medium high levels of depression.Caregivers are less likely to show self-care and self-esteem in the presence of stressful situations.These behaviors are correlated with depression (medium high levels).

Discussion
Compared to nCR, caregivers presented a higher level of depression (medium-high).In addition, there was a substantial difference in the number of in- They could be unabletocope with the stress that the condition of assistance to their sick family memberinvolves.
So our results are in agreement with the statement that assisting a person with dementia can bring emotional resources to the limit and lead to anxious-depressive moods (Schulz, 2008;Papastavrou, 2012).Moreover these intrapsychic problems and depression shows that the caregiver may no longer be able to assist the patient.
These considerations suggest that the screening of intrapsychic factors and depression levels may be an indicator of needs of support (psychotherapeutic intervention, social services support).
Based on the intrapsychic profile (SASB) which emerged, specific psychotherapeutic intervention could be necessary (Benjamin, 2006) for facilitating contact, self-awareness elaboration and integration of emotional experiences (passive adaptation, low self-affirmation, self-criticism), in order to change the life style and to encourage resources necessary for a successful adaptation to the family patient disease condition.So we hypothesize that the changes of intrapsychic behaviors could contribute in decreasing depression and stress linked to the burden.
Sörensen affirms: "Caregiver psychological interventions are effective, but some interventions have primarily domain-specific effects rather than global effects.The differences between intervention types and moderators suggest ways of optimizing interventions".
The use of meditation-based therapies, including Mindfulness Therapy MBSR, the positive effects of which are now recognized by the scientific literature, should be integrated with the reprocessing of the experience of the intra-psychic conflicts that underlie maladaptive lifestyle-related disease.
We think that in this context the use of Holistic Psychotherapy and Mindfulness it could be the most appropriate intervention given the emerged intrapsychic problems.
So it is necessary to make the following considerations: the psychotherapeutic intervention to be effective should be an integrated approach (Behavioral Therapy), Holistic Psychotherapy (Therapeutic Psychosyntesis), meditation practices (Mindfulness-Transpersonal Psychology), relaxation techniques and guided imagery (Brief Psychotherapy) and so on (Sörensen, 2002).
The psychotherapeutic intervention must take account of intra-psychic problems of caregivers of patients affected by Alzheimer's Disease.Therefore a screening of intrapsychic problems is desirable in clinical practice.Given the described personality problems, it can be concluded that a psychotherapeutic approach ( psychotherapy in group or individual session) could , in order to be effective over time and to prevent stress, the sense of uneasiness and the state of depression (Roth, 2005; de Rotrou, 2011; Ducharme, 2011; Negovanska, 2011) address the following issues: Advances in Alzheimer's Disease 1) to give the possibility to elaborate emotional reactions and integrate them; to prevent or face the levels of stress and to realize an acceptance of the illness (Benjamin).
2) to teach the abilities of elaboration of the change of roles and the emotional reactions towards the patient's personality degeneration (anxiety, sense of guilt, anger, embarrassment, sense of loneliness), and of decoding and understanding the patient's antisocial behaviors (García-Alberca, 2012; de Rotrou, 2011; Ducharme, 2011; Hooker, 2002).
3) to integrate the emotional uneasiness for the restoration of a good quality of life within the family nucleus (Benjamin, 2006).
The consequence of this intervention could be the permanence of the patient in the family nucleus.Stress management and reduction is important for the caregiver in order to maintain or restore mental and physical health.
The other important aspect is to create services of practical support that raise the relief load and are of support in this sense.It is very important, especially in Italy, where it is mostly the family that takes care of the patient affected by Alzheimer's disease.The caregiver must not feel alone in this situation (Nápoles, 2010;de Rotrou, 2011).
In conclusion the main finding of the present study is that several dimensions of the caregiver's personality are very problematic and may strongly influence the burden and depressive symptoms of the caregiver.
Our study has several limitations.The first limitation is the small sample of caregivers.
This does not allow us to compare adults and elderly caregivers.Moreover our results provide a snapshot of distress and intrapsychic mechanisms during the caregiving phases without distinguishing time of assistance.The results may differ during the caregiving phases or at other points in the disease journey.Because of the small sample we did not have the data to compare the exact length of time which elapsed from the beginning of assistance.
Another sampling bias was present in the data because all the subjects attended only two institutions and thus were not representative of caregivers in general.
So further studies are necessary especially in the experimentation of psychotherapeutic interventions.

2 )
Structural Analysis of Social Behavior (SASB) Model-Anint A Questionnaire (intrapsychic factors) by L.S. Benjamin [33] [34] (Appendix).The Italian version ASCI (Structural Analysis of Interpersonal Behavior) by P. Scilligo, is validated on the basis of DSMIV and on the Italian population.This test evaluates the mental processes of the personality structure at an intrapsychic and interpersonal level.It includes 36 descriptive items of two series of eight clusters, respectively, of intrapsychic (Oneself) and interpersonal (Other) experiences.The test assesses intrapsychic and interpersonal components of the personality andpredicts the evolution of the mental structure following interpersonal interactions.Interviewed subjects had to respond to 36 items in the questionnaire describing their intrapsychic behaviours during the last year (e.g., "I neglect myself, don't try to develop good skills, ways of being"; "I practice and work on developing worthwhile skills, ways of being"; "I think up ways to hurt and destroy myself.I am my own worst enemy").They are rated on a 10-point scale ranging from 0 (Never) to 10 (All the time).The SASB-Form-A questionnaire describes the structure of personality from normal to pathological.The 36 questions of Form-A are grouped by a specific score correction in 8 clusters (Cl) of intrapsychic "Oneself" and interpersonal "Other" experience.The 8 clusters of "Onself" and "Other" are complementary and opposed (respectively Cl1 and Cl5; Cl2 and Cl6; Cl3 and Cl7; Cl4 and Cl8): high levels in Clusters 1, 2, 3, 4 corresponds to low levels respectively in Clusters 5, 6, 7, 8) (Appendix).Description of the 8 clusters of "Oneself"-Intrapsychic and interpersonal experience (Appendix): SASB Cluster (Cl)1 = Autonomy-Assertive and Separating.SASB Cluster (Cl)2 = Autonomy and Love-Self-Accepting and Exploring.SASB Cluster(Cl)3 = Love Self-Supporting and Appreciative.SASB Cluster (Cl)4 = Love and Control-Self-Care and Development.SASB Cluster (Cl)5 = Control Self-Regulating and Controlling.SASB Cluster (Cl)6 = Control and Hate Self-Critical and Oppressive.SASB Cluster (Cl)7 = Hate Self-Refusing and Annulling.SASB Cluster (Cl)8 = Hate and Autonomy-Self-Negligent and Mentally Absent.

0 - 3
indicates absence of anxiety or depression; 4 -7 indicates medium to medium-high level of anxiety and depression, and 8 -10 indicates a high level of G. M. Velia et al.DOI: 10.4236/aad.2018.74008108 Advances in Alzheimer's Disease depression.

Figure 1 .
Figure 1.Differences between SASB clusters mean values of caregiver and non caregiver groups.
ences in interpersonal behaviors between caregivers and control group.The significant differences are reached in the following clusters: SASB Cl1-Autonomy-Liberating and Forgetting (F = 26,209; p < 0.001); SASB Cl2-Autonomy and Love-Confirming and Understanding (F = 15,528; p < 0.001); SASB Cl3-Love-Caring and Consoling (F = 51,173; p < 0.001); SASB Cl4-Love and Control-Helping and Protecting (F = 35,647; p < 0.000); SASB Cl5-Control-Looking after and Managing (F = 6005; p = 0.015); SASB Cl6-Control and Hate-Belittling and Blaming (F = 36,935; p < 0.001); SASB Cl7-Hate-Assaulting and Refusing (F = 21,577; p < 0.001).In Cl8 a significant difference is not reached.Caregivers' Interpersonal Profile: These patients don't fully promote independence in the relationship with others, by expressing trust and encouraging other people's independent identity; they are not always appreciative and empathic toward accepting other people's difference of opinion; they do not always search to be close to others and do not reach a real intimacy; they control others, by reminding them what they should think, do and say.In extreme cases they may seriously threaten others.They tend to control other people in a positive and negative way and may express behaviors of belittling, blaming or manipulating others.In extreme cases they may ignore and neglect the needs and interests of others.Correlations-SASB and Depression-Caregiver: The results show significant correlations between depression (CDQ) and SASB Clusters.CDQ (medium high levels): SASB Cl1 (r = −0.472;p < 0.001); SASB Cl2 (r = −0.354;p = 0.016); SASB Cl3 (r = −0.469;p < 0.001); SASB CL6 (r = 0.6518; p < 0.001); CL7 (r = 0.409; p < 0.005); CL8 (r = 0.300; p < 0.043).
trapsychic and interpersonal attitudes.CG presented less autonomy in their choices and lower acceptance of their own feelings.These individuals were less spontaneous in their behavior and showed difficulties ingetting in touch with and accepting their deeper feelings.Being unappreciative of themselves, they showed low capacity to treat, console, care for and forgive themselves.If left un-G.M. Velia et al.DOI: 10.4236/aad.2018.74008111 Advances in Alzheimer's Disease treated, these attitudes could hamper the patient's ability to reach and maintain a good quality of life.