|Year : 2017 | Volume
| Issue : 3 | Page : 196-201
A study of the stressor, family environment and family burden in dissociative (conversion) disorder patients
Kamal K Verma, Om P Solanki, Girish C Baniya, Shrigopal Goyal
Department of Psychiatry at S.P. Medical College and Associate Group of P.B.M. Hospital, Bikaner, Rajasthan, India
|Date of Web Publication||14-Sep-2017|
Girish C Baniya
Medical Officer, Department of Psychiatry, S.P. Medical College and Associate Group of P.B.M. Hospital, Bikaner, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: Dissociative disorder is a stress-related disorder usually present in adolescent and younger age group. It is also accompanied with significant impairment in activity of daily living and family relationship. Family environment plays important role in initiation and maintenance of symptoms and this put significant burden on family. Aim and Objective: To study presence of stressor, family environment, and assessment of family burden in dissociative disorder patients. Material and Method: This was a cross-sectional observational study in which 100 dissociatives disorder patients were included after fulfilling inclusion criteria from both inpatients and outpatient department of psychiatry. Results: In our study major part of the sample were women 60 (60%), among them most of were housewife and educated up to primary school. According to a stressor, 63 (63%) patients had family stress/problem and out of them, 35 (58.4) were women. Seventy-four (74%) patients had dissociative convulsion and out of them, 45 (75%) were women. The dissociative disorder patients cause a considerable degree of burden over other family members in both men and women. There is a significant difference found in the family environment in term of personal growth dimension, relationship dimension in both men and women. Conclusion: Present study concludes that dissociative disorder patients cause a considerable degree of burden over other family members in term of leisure, physical, mental, financial, and routines family interrelationship domains. The family environment in term of personal growth dimension, relationship dimension has a casual effect on symptoms of dissociative disorder patients.
Keywords: Conversion disorder, dissociative disorder, family environment, family burden, stressor
|How to cite this article:|
Verma KK, Solanki OP, Baniya GC, Goyal S. A study of the stressor, family environment and family burden in dissociative (conversion) disorder patients. Indian J Soc Psychiatry 2017;33:196-201
|How to cite this URL:|
Verma KK, Solanki OP, Baniya GC, Goyal S. A study of the stressor, family environment and family burden in dissociative (conversion) disorder patients. Indian J Soc Psychiatry [serial online] 2017 [cited 2018 Sep 20];33:196-201. Available from: http://www.indjsp.org/text.asp?2017/33/3/196/214593
| Introduction|| |
Dissociative (Conversion) disorder have sudden onset after preceded by stressful life event or psychological trauma. It is more common in young women. Patients presents with a variety of symptoms including convulsion, aphonia, amnesia, sensory, and trans possession symptoms. Childhood physical or sexual abuse, trauma in adulthood, the stress of examination or failure, quarrel with peers or spouse, interpersonal conflicts, and difficulties of daily life were predominant precipitating factor for this illness.,,
It was predicted that family environment has important role for history of abuse experiences would be associated with dissociation. Family environment characters including inflexibility, poor cohesion, family dissatisfaction, and poor family communication have been usually associated with symptomatic abuse group.
These symptoms appear to produce significant burden on family. However, very few studies conduct on role of family environment, associated psychosocial factor, and burden on family in dissociative disorder.
| Aims and Objective|| |
To study presence of Stressors and role of their family environment and assessment of family burden in dissociative (conversion) disorder patients.
| Material and Methods|| |
The present study was carried out on patients with a diagnosis of dissociative disorders (F44) based on International classification of disease (ICD) 10 criteria attending outdoor (OPD) and indoor (IPD) at Department of Psychiatry, S.P. Medical College and Associated Group of Hospitals, Bikaner (Rajasthan) during the period of January 2015 to July 2015.
Sample: One hundred and twelve patients selected for study, 12 patients were excluded from study based on exclusion criteria. Hundred patients were recruited for the purpose of study after taking informed consent. Various scales were applied on patients to assess sociodemographic, clinical variable, and also assess family environment and burden on family.
Inclusion criteria: Patients either men or women (all age groups) from IPD and OPD clinic diagnosed as Dissociative (conversion) disorder according to ICD-10. Those willing to participate and understood the Questionnaire.
Exclusion criteria: Patients with seizures disorder. Patients having an organic brain disorder. Patients with mental retardation. Those not willing to participate.
Tools: Following scales were used for assessing socio demographic and clinical variable and to assess the family environment and family burden.
Self-designed Proforma: Specifically designed for this study to record socio demographic variables. Personal details of the patients: name, age, sex, marital status, occupation, per capita income, educational status, religion, details of family type, a locality in which the patients reside, and their address with a contact number.
Clinical profile Proforma: This was a self-designed proforma to assess in brief, the clinical profile of the patient. It included-Chief presenting complaints of the patient, total duration of illness, stressor or precipitating factor(s), if any; history of childhood trauma if available; past history if present; family history, nature of treatment sought from various sources; duration between appearance of symptoms and seeking treatment from a psychiatrist; and general physical examination.
Family environment scale:, To measure family environment the Family Environment Scale (F.E.S.) of Moos (1974) has been adopted and standardized in Indian condition by Joshi and Vyas (1987) in Hindi language. To obtain the social, that is, interpersonal environmental characteristics of families and to assess perception of the family environment is the aim of this Scale (F.E.S.). The original F.E.S. questionnaire consists of 90 statements. The statements in the inventory try to identify characteristics of an environment, which would exert or press toward all the important constituents of its main domain, thtat is, cohesion, achievement orientation, moral religious emphasis, and so on. Each item of every sub-scale is on a five-point scale of “four to zero”. There are some negatively framed items for which the scoring is in the reverse direction of weight, that is, “Zero to four”.
Family Burden Interview Schedule (FBIS): FBISis given by Pai and Kapur in 1981, measures the extent pattern of burden experienced by family or primary caregivers of the patients, with regard to disruption of family leisure, family interaction, and effect on physical and mental health of others. This scale measures objective and subjective aspects of burden and it contains six general categories of burden, each having two to six individual items for further investigation. Sub categories include financial burden, effects on family routine, effects on family leisure, effects on family interaction, effects on physical health of family members, and effects on mental health of other family members. Each item is rated on a three-point scale, in which zero is no burden and two is a severe burden. Inter-rater reliability for all items is 0.78 and the correlational validity is 0.72.
Ethical aspects: Study was approved by research review board and ethical committee of the institution. Only those volunteers who are willing to participate in the study and given written consent were included in the study. The interview was conducted in privacy and the confidentiality of the information was ensured.
Statistical analysis: Statistical product and service solution SPSS-23 software was used for statistical analysis. Descriptive data were analyzed by frequency, percentage, mean, and standard deviation. The male–female groups were compared for demographic and clinical variables, with the continuous normally distributed variables by independent t test and the discrete variables by chi-square test.
| Result|| |
Regarding the sociodemographic variable women constitute the major part of our sample 60% (n = 60) and men included in the sample were 40% (n = 40). Out of 60 women, 40 (66.7%) were married, whereas out of total 40 men 27 (67.5%) were married, most of them were 46 (46%) patients were unemployed, out of which 14 (23.3%) were women and 32 (80%) were men followed by housewives, 29 (48.3%). Also, most of the patients were educated up to primary school 36(36%) out of 100 patients and belong to the rural background (83%).
According to ICD-10 (F-44), out of total 100 patients, 74(74%) patients had dissociative convulsion and out of them, 45(75%) were women. Twelve (12%) patients had anesthesia and sensory loss and out of them five (8.3%) and seven (17.5%) patients were women and men, respectively, whereas four (4%) patients had amnesia and out of them three (5%) were women, five (5%) patients had motor disorder out of them three (5%) were women. Four (6.7%) female patients had a disorder of movement and sensation and one (2.5%) male patient had trans and possession. [Figure 1]
According to stressor, 63(63%) patients had family stress/problem and out of them 35(58.4%) were women, 15 (15%) patients had love affair/breaking/disputed, seven (7%) patients had dispute between husband and wife, whereas only two (3.3%) patients had study problem and they all were women. [Table 1].
The result of family environment scale showed that under relationship dimension, mean cohesion score in women and men were 20.40 and 17.87, respectively (P < 0.001). In conflict, mean score in women was 18.33 and in men it was 16.82 (P < 0.05). Under personal growth dimensions, in achievement orientation, mean score of women was 17.65, whereas in the man it was 16.17 (P < 0.05). Intellectual cultural orientation, the mean score of a women was 20.21 and in men it was 16.25 (P < 0.001). In active recreational orientation, mean score of a women was 14.01, whereas in men it was 11.72 (P < 0.001). In moral religious emphasis mean score of women was 21.91 and in men it was 23.97 (P < 0.05).[Table 2].
According to result score on the mean financial burden in woman was 4.96 and in the man, it was 4.95 (P > 0.05). The mean score in disruption in family regular activity and work in women and men was 6.17 and 7.45 (P > 0.05). The mean total score in effect on the physical health of another family member was 1.71 and 2.12 in women and men, respectively, and this difference was statistically significant (P < 0.05). Mean total score of effect on mental health of another family member was 2.93 and 2.87 in women and men, respectively, mean total score of disruption in leisure of the whole family was 3.83 and 3.80 in women and men, respectively, whereas mean total score of disruption in family relationship was 2.85 and 2.90 in women and men, respectively, all these burdens had an insignificant difference (P > 0.05 in all).[Table 3].
|Table 3: Mean score of Family burden interview schedule (FBIS) (N = 100)|
Click here to view
| Discussion|| |
The presence of the stressor, family environment, and family burden in dissociative (conversion) disorder has become a critical focus in dissociative conversion disorder in our study. We found the majority of patients (63%) reported family stress/problems, only 15% patients had some kind of love affair or break up, and 7% reported disputes between husband and wife as their stressor. Two (3.3%) women included in our study stated that they had problems with the education. Total 14% patients had no significant stressor in relation to their symptoms.
Stressors were clearly identified in (90%) volunteers and ranged from disturbed relations with in-laws, engagement/marriage against wishes, disturbed relations with spouse, husband staying abroad, conflict with parents, conflict at work, failure in exam/study problem, love problems, death of spouse, and threat to life. Stressful events can take away the sense of control from an individual, leading to significant incapacitation and emotional distress. The present study showed a higher number of married females suffering from this disorder in comparison to the male volunteers; this finding is the same as in other studies. The nature of stressors differed in both the sexes, in men it ranged from educational issues to familial issues and in women relationship issues were more important, like the sexual relationship is an important issue in younger age groups and financial issues are important in older age groups.
As far as the family environment is concerned, the personal growth dimension and relationship dimension in dissociative conversion disorder patients were significant. In our study, we found that cohesion and conflict were significantly higher in the case of women. It was found that achievement orientation, Intellectual Cultural Orientation (ICO), Active Recreational Orientation (ARO) and Moral Religious Orientation (MRE) were significantly higher in women as compared to that of the men.
We found Cohesion and expressiveness in the family in dissociative (conversion) disorder patient was found to be below average, whereas conflict was found to be above average. We found that independence and achievements orientation in dissociative (conversion) patients were below average. Thus, it can be said that cohesion (i.e.) extent to which family members are concerned and committed to the family and the degree to with family members are helpful and supportive of each other and expressiveness (i.e.), extent to with family members are allowed and exchanged to act openly and to express their feelings is less in disruptive conversion disorder patients. The conflict (i.e.) extent to which the open expression of anger and aggression and generally conflictual interactions are characteristics of the family is very high in dissociative disorder patients. Also, the independent and achievement orientation (i.e.) the extent to with family members are encouraged to be assertive, self-sufficient and make them any decision and the extent to with different types of activities like school and work are into achievement oriented and competitive framework is low in case of dissociative conversion disorder. The extent to with the family members is organized in a hierarchal manner, the rigidity of family members and procedure and so on (i.e.). Control in DCD patients is very strong and intellectual.
Cultural orientation, ARO, MRE, and organization that is the concern of family about political, social, intellectual and cultural activities, sporting, recreational, and festivities type activities, various ethical and religion issues and values and order and organization in family in terms of financial planning and responsibilities and so on was significantly related to symptoms of dissociative conversion disorder of patients in our study or we can say that these dimensions /factors had much impact on dissociative conversion disorder patients in our study.
The results obtained in our study could be because of the reason that we have peculiar cultural and religious beliefs wherein women are not allowed to be very much interactive and socialize among the society. In line with the findings of our studies, many previous studies were conducted in India and Western country. It is difficult to compare the findings of this study to other studies due to lack of similar work in this area. There are, however, reports in the literature, which state that conversion disorder can be disabling and chronic in nature.
The somatization disorder group significantly more family conflict and less family cohesion. Many patients with somatization disorder are raised in an emotionally cold, distant, and unsupportive family environment characterized by chronic emotional and physical abuse.
It was predicted that when the family's affective environment is uncohesive, unexpressive, and conflictual, a history of abuse experiences would be associated with elevated dissociation. More dysfunctional family environment characteristics (inflexibility, poor cohesion, family dissatisfaction, and poor family communication) in the abused person.
Impairment affecting several areas of functioning in adolescents with conversion disorder, as has been demonstrated in this study, has important therapeutic implications.
Any comprehensive management strategy for conversion disorder in adolescents should deal, not only with the psychological conflicts and stressful life situations, but also target the various domains of impairment, to facilitate rehabilitation of the patients. Ignoring impairments in interpersonal, self-fulfillment, and work domains can cause further difficulties resulting in a vicious cycle, leading to chronicity and poor outcome.
In the present study, we found that family member of female dissociative disorder patients had more financial burden and disruption in the leisure of the whole family, whereas the family member of the male dissociative disorder had more burden for regular activity and work and effect on physical health and mental health of another family member. One Study showed that the frequencies of type and severity of family burdens were as follows disruption of routine family activity (65%), financial burden (62%), disruption of family recreation (54%), disruption of family interaction (32%), effect on physical health of others (21%), and effect on mental health of others (11%). Thus, the least common with 11% was the effect on mental health of others.
A study assessed the burden of care among caregivers and substance used group (alcohol and opioids). The result was seen to be severe in all domains, the domains of disruption of family leisure, the effect on the physical health of others, financial burden, disruption of family routine activities, disruption of family interaction, and effect of mental health of others showed no statistical significance between the groups.
It is well established that high degree of burden is associated with women, old age, low-educational level, without employment, and who are taking care of younger patients.
So it can be said that dissociative conversion disorder patients impose some kind of burden over the family, be it a financial burden, physical or mental health or another family member or the interference with the leisure of family or the relationship in the family.
| Conclusion|| |
Our study showed that dissociative disorder was associated with a substantial burden on the family members in term of leisure, physical and mental health, financial burden, and caregiver's routines family interrelationship. It is also clear that the family environment in term of personal growth and relationship dimension have an effect on symptoms of dissociative disorder patients. Cohesion and expressiveness in dissociative disorder patients and excessive negative conflicts in family is related to occurrence or appearance of dissociative symptoms, also, Achievement Orientation, ICO, and ARO played an important role in dissociative disorder patients leading to appearance of dissociative symptoms. Future research should be conducted in a large sample with a prospective design, to study to see the effects of duration of illness and other mediators such as family type, coping, and social support on the family burden.
Limitation: Assessment of burden was cross-sectional and non-blind. Information was obtained from a single family caregiver. Several mediators of burden such as coping, appraisal, expressed emotions, and social support were not assessed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tessner KD, Mittal V, Walker EF. Longitudinal study of stressful life events and daily stressors among adolescents at high risk for psychotic disorders. Schizophr Bull 2011;37:432-41.
Sajid WB, Rashid S, Jehangir S. Hysteria: a symptom or a syndrome. Pak Armed Forces Med J 2005;55:175-79.
Foote B, Smolin Y, Kaplan M, Legatt ME, Lipschitz D. Prevalence of dissociative disorders in psychiatric outpatients. Am J Psychiatry 2006;163:623-29.
Bowman ES, Markand ON. Psychodynamics and psychiatric diagnoses of pseudoseizure subjects. Am J Psychiatry 1996;153:57-63.
Khan MNS, Ahmad S, Arshad N. Birth order, family size and its association with conversion disorders. Pak J Med Sci 2006;22:38-42.
Moos RH, Conceptual and empirical approaches to developing family-based assessment procedures: resolving the case of the Family Environment Scale. Fam Process 1990;29:199-8.
Joshi MC, Vyas OP. Hindi adaptation of Family Environment Scale: rupa psychological centre, Vranasi; 1997.
Pai S, Kapur RL. The burden on the family of a psychiatric patient: development of an interview schedule. Br J Psychiatry 1981;138:332-35.
Chakrabarti S, Raj L, Kulhara P, Avasthi A, Verma SK. Comparison of the extent and pattern of family burden in affective disorders and schizophrenia. Indian J Psychiatry 1995;37:105-12.
] [Full text]
Nasr T, Kausar R. Psychoeducation and the family burden in schizophrenia: a randomized controlled trial. Ann Gen Psychiatry 2009;8:1-6.
Anuradha Srivastava M, Srivstava M. A comparative study of psychosocial factors in male and female patients of conversion disorder. Indian J Prev Soc Med 2011;42:231-36.
Prabhuswamy M, Jairam R, Srinath S, Girimaji S, Seshadri SP. A systematic chart review of inpatient population with childhood dissociative disorder. J Indian Assoc Child Adolescent Mental Health 2006;2:72-77.
Trivedi JK, Singh H, Sinha PK. A clinical study of hysteria in children and adolescents. Indian J Psychiatry 1982;24:70-74.
] [Full text]
Kintner M, Boss PG, Johnson N. The relationship between dysfunctional family environments and family member food intake. J Marriage Fam 1981;43:633-41.
Brown RJ, Schrag A, Trimble MR. Dissociation, childhood interpersonal trauma, and family functioning in patients with somatization disorder. Am J Psychiatry 2005;162:899-05.
Narang DS, Contreras JM. The relationships of dissociation and affective family environment with the intergenerational cycle of child abuse. Child Abuse Negl 2005;29:683-99.
Drerup Stokes L, McCord D, Aydlett L. Family environment, personality, and psychological symptoms in adults sexually abused as children. J Child Sex Abuse 2013;22:658-76.
Keertish N, Sharma I. Impairment and classroom environment in adolescents with conversion disorder. J Indian Assoc Child Adolescent Mental Health 2015;11:99-120.
Sen SK, Nath K. A clinical study of family burden in chronic schizophrenia. Dysphrenia 2012;3:153-57.
Shareef N, Srivastava M, Tiwari R. Burden of care and quality of life (QOL) in opioid and alcohol abusing subjects. Int J Med Sci Public Health 2013;2:880-84.
Singh K, Kumar R, Sharma N, Nehra DK. Study of burden in parents of children with mental retardation. J Indian Health Psychol 2014;8:13-20.
[Table 1], [Table 2], [Table 3]