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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

Dissociative (Conversion) disorder have sudden onset
after preceded by stressful life event or psychological
trauma.[1] 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.[2-4]
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.[5]
Address for correspondence:
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
Access this article online
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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.
This is an open access article distributed under the terms of the Creative Commons
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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
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:[6,7] 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):[8] 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
Indian Journal of Social Psychiatry | Volume 33 | Issue 3 | July-September 2017
family leisure, family interaction, and effect on physical
and mental health of others.[9] 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.[10] 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 malefemale 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,
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Verma, et al.: Contributing factor in dissociative (conversion) disorder patients

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].

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)
Mean SD
Financial Burden 4.96 1.43
Disruption in family regular activity and work 6.17 1.84
Effect on Physical Health of Another family
1.71 0.69
member
Effect on mental health of another family
2.93 1.38
member
Disruption in leisure of whole family 3.83 1.29
Disruption in family relationship 2.85 1.19
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.[11] Stressful events can take
away the sense of control from an individual, leading to
significant incapacitation and emotional distress.[12] 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.[13]
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
Indian Journal of Social Psychiatry | Volume 33 | Issue 3 | July-September 2017
Male (n = 40) t test P value
Mean SD
4.95 1.48 0.056 0.955
7.45 2.49 1.691 0.094
2.12 1.01 2.392 0.019
2.87 0.85 0.237 0.813
3.8 1.58 0.029 0.977
2.90 0.90 0.226 0.822
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.[14] 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.[15]
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Verma, et al.: Contributing factor in dissociative (conversion) disorder patients
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.[16] More dysfunctional family
environment characteristics (inflexibility, poor cohesion,
family dissatisfaction, and poor family communication) in
the abused person.[17]
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.[18]
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[19] 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[20] 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.[21]
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
200
caregivers 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
Nil
Conflicts of interest
There are no conflicts of interest.
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