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Original Article

A Study of the Stressor, Family Environment and Family Burden in

Dissociative (Conversion) Disorder Patients

Abstract Kamal. K. Verma, Om

Background: Dissociative disorder is a stress-related disorder usually present in adolescent and P. Solanki, Girish C.
younger age group. It is also accompanied with significant impairment in activity of daily living Baniya, Shrigopal
and family relationship. Family environment plays important role in initiation and maintenance of Goyal
symptoms and this put significant burden on family. Aim and Objective: To study presence of
Department of Psychiatry at S.P.
stressor, family environment, and assessment of family burden in dissociative disorder patients. Medical College and Associate
Material and Method: This was a cross-sectional observational study in which 100 dissociatives Group of P.B.M. Hospital, Bikaner,
disorder patients were included after fulfilling inclusion criteria from both inpatients and outpatient Rajasthan, India
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.

Key Words: Conversion disorder, dissociative disorder, family environment, family burden, stressor

Introduction These symptoms appear to produce significant burden

on family. However, very few studies conduct on role of
Dissociative (Conversion) disorder have sudden onset
family environment, associated psychosocial factor, and
after preceded by stressful life event or psychological
burden on family in dissociative disorder.
trauma.[1] It is more common in young women. Patients
presents with a variety of symptoms including convulsion, Aims and Objective
aphonia, amnesia, sensory, and trans possession symptoms.
Childhood physical or sexual abuse, trauma in adulthood, To study presence of Stressors and role of their family
the stress of examination or failure, quarrel with peers or environment and assessment of family burden in
spouse, interpersonal conflicts, and difficulties of daily life dissociative (conversion) disorder patients.
were predominant precipitating factor for this illness.[2-4]
Material and Methods
It was predicted that family environment has important
role for history of abuse experiences would be associated The present study was carried out on patients with
with dissociation. Family environment characters including a diagnosis of dissociative disorders (F44) based on
inflexibility, poor cohesion, family dissatisfaction, and poor International classification of disease (ICD) 10 criteria
family communication have been usually associated with attending outdoor (OPD) and indoor (IPD) at Department
symptomatic abuse group.[5] of Psychiatry, S.P. Medical College and Associated Group
of Hospitals, Bikaner (Rajasthan) during the period of
Address for correspondence: January 2015 to July 2015.
Dr. Girish C. Baniya,
Medical Officer, Department of Psychiatry, S.P. Medical College and
Associate Group of P.B.M. Hospital, Bikaner, Rajasthan, India.
E-mail: girishdrbaniya@gmail.com This is an open access article distributed under the terms of the Creative Commons
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Access this article online tweak, and build upon the work noncommercially, as long as the author is credited and
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DOI: 10.4103/0971-9962.214593
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.

196 2017 Indian Journal of Social Psychiatry | Published by Wolters Kluwer - Medknow
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Verma, et al.: Contributing factor in dissociative (conversion) disorder patients

Sample: One hundred and twelve patients selected for family leisure, family interaction, and effect on physical
study, 12 patients were excluded from study based on and mental health of others.[9] This scale measures
exclusion criteria. Hundred patients were recruited for the objective and subjective aspects of burden and it contains
purpose of study after taking informed consent. Various six general categories of burden, each having two to six
scales were applied on patients to assess sociodemographic, individual items for further investigation. Sub categories
clinical variable, and also assess family environment and include financial burden, effects on family routine, effects
burden on family. on family leisure, effects on family interaction, effects on
physical health of family members, and effects on mental
Inclusion criteria: Patients either men or women (all age
health of other family members. Each item is rated on a
groups) from IPD and OPD clinic diagnosed as Dissociative
three-point scale, in which zero is no burden and two is a
(conversion) disorder according to ICD-10. Those willing
severe burden.[10] Inter-rater reliability for all items is 0.78
to participate and understood the Questionnaire.
and the correlational validity is 0.72.
Exclusion criteria: Patients with seizures disorder. Patients
Ethical aspects: Study was approved by research review
having an organic brain disorder. Patients with mental
board and ethical committee of the institution. Only those
retardation. Those not willing to participate.
volunteers who are willing to participate in the study and
Tools: Following scales were used for assessing socio given written consent were included in the study. The
demographic and clinical variable and to assess the family interview was conducted in privacy and the confidentiality
environment and family burden. of the information was ensured.
Self-designed Proforma: Specifically designed for this Statistical analysis: Statistical product and service
study to record socio demographic variables. Personal solution SPSS-23 software was used for statistical analysis.
details of the patients: name, age, sex, marital status, Descriptive data were analyzed by frequency, percentage,
occupation, per capita income, educational status, religion, mean, and standard deviation. The malefemale groups
details of family type, a locality in which the patients were compared for demographic and clinical variables,
reside, and their address with a contact number. with the continuous normally distributed variables by
Clinical profile Proforma: This was a self-designed independent t test and the discrete variables by chi-square
proforma to assess in brief, the clinical profile of the test.
patient. It included-Chief presenting complaints of the
Result
patient, total duration of illness, stressor or precipitating
factor(s), if any; history of childhood trauma if available; Regarding the sociodemographic variable women constitute
past history if present; family history, nature of treatment the major part of our sample 60% (n = 60) and men
sought from various sources; duration between appearance included in the sample were 40% (n = 40). Out of 60
of symptoms and seeking treatment from a psychiatrist; women, 40 (66.7%) were married, whereas out of total 40
and general physical examination. men 27 (67.5%) were married, most of them were 46 (46%)
patients were unemployed, out of which 14 (23.3%) were
Family environment scale:[6,7] To measure family
women and 32 (80%) were men followed by housewives,
environment the Family Environment Scale (F.E.S.) of
29 (48.3%). Also, most of the patients were educated up to
Moos (1974) has been adopted and standardized in Indian
primary school 36(36%) out of 100 patients and belong to
condition by Joshi and Vyas (1987) in Hindi language.
the rural background (83%).
To obtain the social, that is, interpersonal environmental
characteristics of families and to assess perception of the According to ICD-10 (F-44), out of total 100 patients,
family environment is the aim of this Scale (F.E.S.). The 74(74%) patients had dissociative convulsion and out
original F.E.S. questionnaire consists of 90 statements. The of them, 45(75%) were women. Twelve (12%) patients
statements in the inventory try to identify characteristics of had anesthesia and sensory loss and out of them five
an environment, which would exert or press toward all the (8.3%) and seven (17.5%) patients were women and men,
important constituents of its main domain, thtat is, cohesion, respectively, whereas four (4%) patients had amnesia and
achievement orientation, moral religious emphasis, and so out of them three (5%) were women, five (5%) patients
on. Each item of every sub-scale is on a five-point scale of had motor disorder out of them three (5%) were women.
four to zero. There are some negatively framed items for Four (6.7%) female patients had a disorder of movement
which the scoring is in the reverse direction of weight, that and sensation and one (2.5%) male patient had trans and
is, Zero to four. possession. [Figure 1]
Family Burden Interview Schedule (FBIS):[8] FBISis According to stressor, 63(63%) patients had family stress/
given by Pai and Kapur in 1981, measures the extent problem and out of them 35(58.4%) were women, 15
pattern of burden experienced by family or primary (15%) patients had love affair/breaking/disputed, seven
caregivers of the patients, with regard to disruption of (7%) patients had dispute between husband and wife,

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Verma, et al.: Contributing factor in dissociative (conversion) disorder patients

whereas only two (3.3%) patients had study problem and and in men it was 16.25 (P < 0.001). In active recreational
they all were women. [Table 1]. orientation, mean score of a women was 14.01, whereas in
men it was 11.72 (P < 0.001). In moral religious emphasis
The result of family environment scale showed that under
mean score of women was 21.91 and in men it was 23.97
relationship dimension, mean cohesion score in women and
(P < 0.05).[Table 2].
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 According to result score on the mean financial burden in
16.82 (P < 0.05). Under personal growth dimensions, in woman was 4.96 and in the man, it was 4.95 (P > 0.05).
achievement orientation, mean score of women was 17.65, The mean score in disruption in family regular activity and
whereas in the man it was 16.17 (P < 0.05). Intellectual work in women and men was 6.17 and 7.45 (P > 0.05). The
cultural orientation, the mean score of a women was 20.21 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].

Discussion
The presence of the stressor, family environment, and
Figure 1: Distribution of cases according to ICD-10 (F-44) family burden in dissociative (conversion) disorder has

Table 1: Distribution of cases according to stressor (N = 100 )

Stressor Sex Total
Female (n = 60) Male (n = 40)
No. % No. % No. %
Family Stress/Problems 35 58.3 28 70.0 63 63.0
Love affair/Breakups 8 13.4 6 15.0 14 14.0
Dispute between Husband and Wife 5 8.3 2 5.0 7 7.0
Study Problem 2 3.3 0 0 2 2.0
Nil 10 16.7 4 10.0 14 14.0
Total 60 100 40 100 100 100

Table 2: Mean score of Family Environment Scale (N = 100)

Female (n = 60) Male (n = 40) t test P value
Mean SD Mean SD
Cohesion (C) 20.40 3.57 17.87 3.22 3.635 0.000
Relationship Dimension Expressiveness (E) 12.21 3.91 10.90 2.43 1.893 0.061
Conflict (Co) 18.33 3.57 16.82 3.22 2.147 0.034
Independence (Ind) 17.71 3.71 16.97 3.19 1.034 0.304
Achievement Orientation(AO) 17.65 3.03 16.17 3.46 2.249 0.027
Intellectual Cultural
Personal Growth 20.21 1.91 16.25 2.58 8.802 0.000
Orientation (ICO)
Dimension
Active Recreational
14.01 2.51 11.72 1.86 4.926 0.000
Orientation (ARO)
Moral Religious Emphasis
21.91 3.65 23.97 3.20 -2.897 0.005
(MRE)
System Maintenance Organization (O) 21.88 2.97 21.60 2.35 0.506 0.614
Dimension Control (Con) 22.55 3.35 23.65 2.65 1.742 0.085

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Verma, et al.: Contributing factor in dissociative (conversion) disorder patients

Table 3: Mean score of Family burden interview schedule (FBIS) (N = 100)

FBIS Female (n = 60) Male (n = 40) t test P value
Mean SD Mean SD
Financial Burden 4.96 1.43 4.95 1.48 0.056 0.955
Disruption in family regular activity and work 6.17 1.84 7.45 2.49 1.691 0.094
Effect on Physical Health of Another family
1.71 0.69 2.12 1.01 2.392 0.019
member
Effect on mental health of another family
2.93 1.38 2.87 0.85 0.237 0.813
member
Disruption in leisure of whole family 3.83 1.29 3.8 1.58 0.029 0.977
Disruption in family relationship 2.85 1.19 2.90 0.90 0.226 0.822

become a critical focus in dissociative conversion disorder and supportive of each other and expressiveness (i.e.),
in our study. We found the majority of patients (63%) extent to with family members are allowed and exchanged
reported family stress/problems, only 15% patients had to act openly and to express their feelings is less in
some kind of love affair or break up, and 7% reported disruptive conversion disorder patients. The conflict (i.e.)
disputes between husband and wife as their stressor. Two extent to which the open expression of anger and aggression
(3.3%) women included in our study stated that they had and generally conflictual interactions are characteristics of
problems with the education. Total 14% patients had no the family is very high in dissociative disorder patients.
significant stressor in relation to their symptoms. Also, the independent and achievement orientation (i.e.)
the extent to with family members are encouraged to be
Stressors were clearly identified in (90%) volunteers and
assertive, self-sufficient and make them any decision and
ranged from disturbed relations with in-laws, engagement/
the extent to with different types of activities like school
marriage against wishes, disturbed relations with spouse,
and work are into achievement oriented and competitive
husband staying abroad, conflict with parents, conflict at
framework is low in case of dissociative conversion
work, failure in exam/study problem, love problems, death
disorder.[14] The extent to with the family members is
of spouse, and threat to life.[11] Stressful events can take
organized in a hierarchal manner, the rigidity of family
away the sense of control from an individual, leading to
members and procedure and so on (i.e.).Control in DCD
significant incapacitation and emotional distress.[12] The
patients is very strong and intellectual.
present study showed a higher number of married females
suffering from this disorder in comparison to the male Cultural orientation, ARO, MRE, and organization that is
volunteers; this finding is the same as in other studies.[13] the concern of family about political, social, intellectual and
The nature of stressors differed in both the sexes, in men cultural activities, sporting, recreational, and festivities type
it ranged from educational issues to familial issues and activities, various ethical and religion issues and values
in women relationship issues were more important, like and order and organization in family in terms of financial
the sexual relationship is an important issue in younger planning and responsibilities and so on was significantly
age groups and financial issues are important in older age related to symptoms of dissociative conversion disorder of
groups. patients in our study or we can say that these dimensions
/factors had much impact on dissociative conversion
As far as the family environment is concerned, the
disorder patients in our study.
personal growth dimension and relationship dimension in
dissociative conversion disorder patients were significant. The results obtained in our study could be because of the
In our study, we found that cohesion and conflict were reason that we have peculiar cultural and religious beliefs
significantly higher in the case of women. It was found that wherein women are not allowed to be very much interactive
achievement orientation, Intellectual Cultural Orientation and socialize among the society. In line with the findings of
(ICO), Active Recreational Orientation (ARO) and Moral our studies, many previous studies were conducted in India
Religious Orientation (MRE) were significantly higher in and Western country. It is difficult to compare the findings
women as compared to that of the men. of this study to other studies due to lack of similar work
in this area. There are, however, reports in the literature,
We found Cohesion and expressiveness in the family in
which state that conversion disorder can be disabling and
dissociative (conversion) disorder patient was found to be
chronic in nature.
below average, whereas conflict was found to be above
average. We found that independence and achievements The somatization disorder group significantly more family
orientation in dissociative (conversion) patients were below conflict and less family cohesion. Many patients with
average. Thus, it can be said that cohesion (i.e.) extent to somatization disorder are raised in an emotionally cold,
which family members are concerned and committed to the distant, and unsupportive family environment characterized
family and the degree to with family members are helpful by chronic emotional and physical abuse.[15]

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Verma, et al.: Contributing factor in dissociative (conversion) disorder patients

It was predicted that when the family's affective caregivers routines family interrelationship. It is also clear
environment is uncohesive, unexpressive, and conflictual, that the family environment in term of personal growth
a history of abuse experiences would be associated and relationship dimension have an effect on symptoms of
with elevated dissociation.[16] More dysfunctional family dissociative disorder patients. Cohesion and expressiveness
environment characteristics (inflexibility, poor cohesion, in dissociative disorder patients and excessive negative
family dissatisfaction, and poor family communication) in conflicts in family is related to occurrence or appearance
the abused person.[17] of dissociative symptoms, also, Achievement Orientation,
ICO, and ARO played an important role in dissociative
Impairment affecting several areas of functioning in
disorder patients leading to appearance of dissociative
adolescents with conversion disorder, as has been
symptoms. Future research should be conducted in a large
demonstrated in this study, has important therapeutic
sample with a prospective design, to study to see the effects
implications.
of duration of illness and other mediators such as family
Any comprehensive management strategy for conversion type, coping, and social support on the family burden.
disorder in adolescents should deal, not only with the
Limitation: Assessment of burden was cross-sectional and
psychological conflicts and stressful life situations, but
non-blind. Information was obtained from a single family
also target the various domains of impairment, to facilitate
caregiver. Several mediators of burden such as coping,
rehabilitation of the patients. Ignoring impairments in
appraisal, expressed emotions, and social support were not
interpersonal, self-fulfillment, and work domains can cause
assessed.
further difficulties resulting in a vicious cycle, leading to
chronicity and poor outcome.[18] Financial support and sponsorship
In the present study, we found that family member of female Nil
dissociative disorder patients had more financial burden and Conflicts of interest
disruption in the leisure of the whole family, whereas the There are no conflicts of interest.
family member of the male dissociative disorder had more
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