INTRODUCTION

Adolescence is a crucial period of one’s life in which an individual undergoes the transition from childhood to adulthood. This is a stage of human development in which major physical, social and emotional changes. Adolescents need to adapt to these changes. Stress increases if they are unable to adjust in unfavorable conditions ( Kaur, 2008 ) . This may lead to psychiatric problems ( Jaureguizar, 2018 ). Stress may also be related to the family, student-teacher relationship, academic performance or risk of school failure if they are unable to cope adequately ( Kaur, 2008 ) .

Dissociation is a defense mechanism which helps individuals cope with unwanted conditions. One of the most typical subgroups of mental diseases in the world are dissociative (conversion) disorders, sometimes known as hysteria. The latest Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), states that dissociative disorders generally involve impairments in the integration of all of the following: consciousness, memory, identity, emotion, perception, body representation, motor control, and behaviour. The main diagnostic requirement for conversion disorders is the presence of one or more symptoms of altered voluntary motor or sensory functions which are distressing or significantly impairing daily functioning. These are not better explained by other physical or mental illnesses. Movement abnormalities, non-epileptic seizures, sensory perception loss, and motor weakness are examples of typical conversion symptoms ( APA, 2013 ) . Dissociative (conversion) disorders have complex relationships with the patients’ bodies, minds, and sociocultural environments, according to ( Zhao (2018) ) . Stressful life events, traumas, and difficulty adjusting to new situations are positively associated with later dissociative and conversion symptoms in children ( Diseth, 2005 ; Shapiro, 2012 ) . Family conflict, parental divorce, learning difficulties, skipping school, bullying, scolding, and punishment are the most frequent stresses or traumas ( de Gusmão, 2014 ; Doss, 2017 ) . In addition, dissociative (conversion) disorders have been linked to parental marital status, parenting style, family economics, and children abandoned by parents ( Zhao, 2018 ) . In the dissociative disorder, the individual becomes disconnected from their surroundings⁹. Dissociative disorder is significantly associated with childhood abuse, stress and traumatic events ( Sanders, 2004 ) . Indian studies show that this disorder is very common and the prevalence rate is as high as 31% in inpatients and 15% in outpatients ( Ranjan, 2016 ) found Stress is evident in the school, family and body image areas (Sharma, 2005).

Adolescents with dissociative disorder had poor coping strategies to deal with stressors. The common stressors in children and adolescents with dissociative disorder are adjustment problems in school, with family, with peers, and fear of scolding, punishment and sexual abuse ( Ranjan, 2016 ).

The factors related to a child´s adjustment problem is their inability to adjust socially because of a lack of social competence. Each and every individual differs in terms of life changes according to time, circumstances and certain events. For coping with these conditions, children and adolescents need to adjust to different situations ( Hampel, 2016 ) . Children who were diagnosed with the dissociative disorder are socially uncoordinated, sentimental, and not able to manage or face adverse situations ( Rana, 2015 ) . The children and adolescents with dissociative disorder had very poor adaptability which may lead to distress and disturbance in sleep ( Chardon, 2016 ) . A patient with a dissociative disorder had significantly higher levels of physical and emotional abuse and dissociative symptoms are related to overwhelming stress ( Watson, 2006 ). Because of stressors children and adolescents are at risk of developing poor adjustment, such as, rejection, school difficulties, low self- esteem and emotional difficulties ( Hampel, 2016 ) .

Adolescents with dissociative disorder have poor cognitive ability ( Ranjan, 2016 ). A study conducted by ( Ranjan et al (2016) ) , on the relationship between cognitive function and adjustment difficulties among children and adolescents with dissociative disorder found a significant association between IQ and adjustment in school; visual learning and memory; and adjustment in school and overall adjustment. More dissociative symptoms and inpatient treatment in adolescence were significantly associated with a lower level of psychosocial stressors in adulthood. Because of adjustment difficulties, children and adolescents are not able to cope with the stress which could be related to family, society, school or peers (Thomas, 2008). Adjustment difficulties in dissociative disorder have not been explored much in an Indian context. Thus, the present study aims to assess the adjustment difficulties among adolescents with dissociative disorder in this context.

MATERIALS AND METHODS

This was a non-experimental, cross-sectional study which was conducted at Child and Adolescent Psychiatry OPD of a tertiary care center in North India. A purposive sampling technique was used to draw the sample. The study was approved by the Institutional Ethics Committee (IEC) Ref.code:91^st ECM IID-b/PII. A written informed consent from the guardians and assent from the study subjects was obtained. A total of 85 patients with dissociative disorder attending the Child and Adolescent OPD were screened for possible inclusion out of which 25 were excluded. The reason for exclusion was age <12 years (n=12), presence of other psychiatric comorbidity (n=6), intellectual disability (n=4) and not willing to participate in the study (n=3). 60 adolescents diagnosed with dissociative disorder by a psychiatrist as per the DSM-V criteria were included in the study. Sociodemographic (age, gender, domicile, birth order, educational status, family monthly income, school attendance) and clinical profile (past traumatic illness, psychiatric comorbidity such as anxiety and mild depression included, any role model) details of symptom presentation, present stressors, past traumatic event, family history of any psychiatric illness, psychiatric comorbidity & any role model were assessed as per a semi-structured proforma. K-SADS-PL (Kiddie Schedule for Affective Disorders & Schizophrenia- Present and Lifetime) for DSM-5¹³ was used for ruling out any psychiatric comorbidities in the adolescents. Adjustment difficulties in the adolescents were assessed by the Bell Adjustment Inventory (Modified Form)¹⁴. The Bell Adjustment Inventory (student form), was originally developed by Bell, (1934) and used for evaluating adjustment in specific areas, namely, Home, Health, Social & Emotional, as well as overall adjustment. In this study, the “Mohsin-Shamshad Adaptation of Bell Adjustment Inventory” which is the Hindi version of BAI, developed by Hussain, (1969) was used. It has 124 items with a yes/no/don’t know response. The higher scores indicate greater adjustment difficulties. Data obtained was analyzed using the Statistical Package for the Social Sciences (SPSS, version 16.0). Both descriptive and inferential statistics were used for the analysis. Descriptive statistical analysis was used to calculate mean, standard deviation, range and frequency of socio-demographic, clinical variables and adjustment difficulty. The relationship of adjustment with sociodemographic and clinical variables was assessed by the inferential statistical analysis. T-test and ANOVA were used for comparison between adjustment difficulties and sociodemographic and clinical variables.

RESULTS

The mean age of adolescents with dissociative disorder was 14.9 ±1.15 years. The majority were female (70%) and belonged to a rural domicile (66.66%). Most of the adolescents had a birth order of third and above among the siblings and were educated up to high school (41.66%). However, most of the adolescents had irregular school attendance (83.33%). More than fifty percent had a family income of Rs 20000 (241 USD approx.) and above. The clinical profile shows that most of the patients reported no history of past traumatic events (88.33%) and no record of familial psychiatric illness (83.33%). Many of the patients had no psychiatric comorbidity (including anxiety & mild depression) (73.33%). The majority of the patients had no role model (88.33%) and most had poor adjustment (80%). The mean score of BAI -MHJ was 73.71 ± 16.79. The minimum score is 34 and the maximum score is 105 out of 124.

Table 1 shows that the mean score of BAI -MHJ was 73.71 ± 16.79. The minimum score is 34 and the maximum score is 105 out of 124. The results show that adolescents with dissociative disorder had poor adjustment. The mean score of the emotional (21.00± 5.63) and social domain (20.35± 5.76) was higher than the home and health domain, which implies that adolescents had more adjustment difficulties relating to the former than the latter.

Table 2 shows that there is no significant difference between gender and adjustment difficulties (p<0.05). There is no significant difference in domicile, school attendance, any past traumatic event, family history of psychiatric illness, psychiatric comorbidity (includes anxiety and mild depression) or role model with the adjustment difficulties among adolescents.

Table 3 Shows that there is no significant difference found in birth order, education, and monthly family income with the adjustment difficulties.

DISCUSSION

The present study explored the adjustment difficulties among adolescents with dissociative disorder. In our study the findings shows that the mean age of the patients was 14.9 ± 1.153 years. Similar findings were found in another study ( Dixit, 2019 ) in which assessment of the sociodemographic characteristics, namely, age, gender, and education in adolescents with dissociative disorder, found that females comprise a major part of the sample and the mean age of patients was 13.32±1.54. The male/female ratio was also similar. In the present study, the majority of the patients belonged to a rural background and most of them were female. In similar studies conducted by ( Ranjan et al (2016) ) and ( Prabhuswamy (2002) ) , the results were similar for a similar majority from a similar background. In our study, most of the patients were third or above in their birth order. Most of the patients had passed high school and had a monthly family income of >20,000 rupees (241 USD approx.). ( Dixit (2019) ) also found that the majority of patients were studying in the 9-10th standard and monthly family income was similar. Irregular school attendance (83.33%) in this study was also observed in a similar study done by ( Ranjan et al (2016) ) .

The majority of patients achieved developmental milestones on time and most had no traumatic event or family history of psychiatric illness. Most had no psychiatric comorbidity or a role model.

In the present study the mean score of BAI was 73.71 ± 16.79 which suggests that the majority of patients had poor adjustment. This was relatively higher in the emotional domain (21.00±5.63) and social domain (20.35±5.76) than the health domain (17.13±4.44) and home domain (15.23±4.61). The present study shows higher adjustment difficulties in the emotional & social domain. A similar study conducted by ( Ranjan et al (2014) ) also found poor adjustment in various domains suggesting that children and adolescents with a dissociative disorder had poor adjustment. ( Dvir et al (2014) ) states that negative emotional states are related to stress and students had irritability, worries, and interpersonal disturbances suggesting poor adjustment. ( Malhi et al (2002) ) also found that children had stress related to school and family problems.

Adjustment is vital among adolescents. Parents need to create an environment so that the adolescents can express their emotions without any hesitation.

CONCLUSION

The major finding of the present study suggests that adolescents with dissociative disorder had poor adjustment. Higher scores were found in the emotional and social domains than in the other two domains, indicating poor adjustment. This may be related to the inability to adapt in the family, school and social environment. , adjustment difficulties should be addressed in such adolescents in order to improve their outcomes.

Limitations of the study

The present study was limited to a small sample size. Further the interpretation of the scoring of BAI-MHJ was not available thus making the results not very clear and detailed.

Nil.

Conflicts of interest: There are no conflicts of interest.

Contribution: Concept: first three authors; R wrote the 1^st draft of manuscript and V and P helped in the literature search; E helped in editing. All the authors checked the manuscript for language, analysis of data and interpretation.

Acknowledgements: The authors sincerely appreciate and thank all the patients who participated & agreed to take part in this research.

Ethics approval: The study was approved by the Institutional Ethics Committee of King George’s Medical University.Ref: code:91 ECM IID-b/PII.

Patient consent for publication: Obtained.

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