Perceived parental style, cognitive style, and resilience in females with dissociative disorder in India.

BACKGROUND: Dissociative disorders are theorized to be caused by extremely stressful situations, including abuse, kidnapping, incest, rape, and other threats of death. Such childhood experiences alter one's cognitive style as well as one's ability to deal with adverse situations. It is important to understand how cognitive style influences the relationship between parental style and resilience to help in the management. We aimed to assess the relationship between perceived parental styles and resilience mediated by cognitive styles in females with dissociative disorder.
MATERIALS AND METHODS: Sample comprised 60 females between 18 and 50 years of age with dissociative disorder (International Classification of Diseases-10 criteria) in a cross-sectional observational study. Perceived parental style of the participant was assessed using s-EMBU, cognitive style using the Cognitive Style Inventory, and resilience using the Conner and Davidson's Resiliency Scale. Data were analyzed using Shapiro-Wilk to assess the normality of the data and Spearman rank correlation for determining the relationship between the variables.
RESULTS: The results indicated a significant relationship between emotional warmth and systematic-cognitive style (r s= 0.398, P = 0.01) and between systematic-cognitive style and high resilience (r s= 0.256, P = 0.05). A significant regression equation was found (F[1, 58] = 9.146, P < 0.004), with an R2= 0.136 to predict systematic-cognitive style based on emotional warmth as the perceived parental style. To predict resilience based on systematic-cognitive style, a significant regression equation was found (F[1, 58] = 6.006, P < 0.017), with an R2= 0.094.
CONCLUSION: The more emotional warmth was perceived by the participants, the more systematic they were in their perception of the environment, in turn being more resilient. The study findings help in establishing protective psychological factors in dissociative disorder.

INTRODUCTION

Dissociative disorders are characterized by “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior.”[1] Dissociation may affect a person subjectively in the form of “made” thoughts, feelings, and actions. These are thoughts or emotions seemingly coming out of nowhere or finding oneself carrying out an action as if it were controlled by a force other than oneself.[2] The prevalence of dissociative disorder in India was attempted to be studied at the National Institute of Mental Health and Neurosciences between 1999 and 2008 and was reported between the ranges of 1.5–15/1000 persons. They also reported female preponderance and dissociative motor and convulsion disorders to be the most commonly diagnosed.[3]

As it is also referred to as conversion disorder in the International Classification of Disease-10 (ICD-10), it signifies substitution of somatic symptom for a repressed idea. In addition to the psychoanalytic perspective of this condition, learning theories have also contributed in tracing its roots. These theorists propose that symptoms of this illness are learned in childhood and are triggered as a means of coping.[4] Overall, a strong association has also been found between adverse childhood experience and the presence of dissociative symptoms in adulthood. Windows of vulnerability may be a precursor to the development of shutdown dissociation. This hypothesis has been supported by the evidence that experienced events are more important than witnessed events; however, challenge the hypothesis that “life-threatening” events are a critical determinant.[4] Recent research indicates that high levels of dissociation in mothers are associated with disturbed, often dissociative-like attachment behavior in their children.[5] In another study, the early presence of these attachment disturbances prospectively predicted higher levels of dissociation in late adolescence.[6] Early experiences influence how an individual views the world and can deal with difficulties, not only in individuals with dissociative disorder but also in the general population. Therefore, it is important to understand the association of these variables in such individuals. Exposure to rejecting or ambivalent caregiving has been linked with a sense of insecurity that may lead to deviations in personality development.[7] Perceived parental style differs from parental style, conceptually as well as practically. Findings suggest that substantial difference exists between parents' and children's account of their interaction. The greater the disparity, the greater are the parent-child conflicts.[8] However, it is imperative to understand the perception of parenting style by individuals themselves as that further influences how they perceive other relationships and defines their attitudes and values.

Cognitive styles are personality dimensions which influence attitudes, values, and social interaction. Systematic- and intuitive-cognitive styles are similar to Pask's holist-serialist model.[9] Systematic style reflects step-by-step approach of problem-solving as is with the serialist approach. The intuitive style incorporates utilizing significant amount of information from the beginning based on one's choice, as is with the holistic approach.[10] Growing support has been found for a relationship between negative cognitive style and psychopathology.[1011] It was found to be related with primary control, secondary control, and disengagement type of coping.[11]

Resilience is “an interactive concept that is concerned with the combination of serious risk experiences and a relatively positive psychological outcome despite those experiences.”[12] Resilience has been understood from multiple standpoints varying from recovering during risks to sustaining the pursuit of the positive. Advancement in the theoretical framework of resilience has been made by Leipold and Greve's (2009) theory of coping, resilience, and development.[13]

Understanding the role of these three integral concepts may help in determining possible predisposing, precipitating, and perpetuating causes that may contribute to this condition. Fletcher's meta-models for stress, emotions, and performance state that stressors that arise are mediated by one's perceptions, appraisal, and coping which in turn result in positive or negative feeling states and outcome.[13] Findings support that authoritative style enhances one's self-esteem, is associated with higher educational qualification, possess active coping styles, and exhibits better adjustment and greater resilience.[14] Prince-Embury (2006) reflected that researchers and theorists primarily propose a systemic perspective of resilience, in which child characteristics and environmental support create a buffer for the adverse outcomes of a negative event.[15] Young's schema theory (2001) postulates that maladaptive schemata may be stemming from inadequate parenting in the form of repeated criticism or rejection. Bandura's Social Learning Theory (1977) hypothesizes that one learns vicariously through modeling of parents' behavior. This view has been supported by Stark's model of “depressogenic” style of thinking.[16] Individuals who rate their parents as being more abusive and neglectful reported a greater degree of depression and that this relationship was mediated by dysfunctional cognitive style.[17] Zarbakhsh et al. found a clear relationship between perceived parental styles and cognitive learning styles with students with authoritarian or permissive parents using problem-solving models in anxious situations.[18] The systematic- and intuitive-cognitive styles have shown a positive correlation with resilience.[19] While resilience is not regarded as a personality trait, the construct is associated with enhancing strength and ability. The best parenting style for developing resilience has been found to be authoritative style and acceptance involvement style with the ability of predicting resiliency of children.[2021] Resilience has often been associated with interventions. The effect size of the consequent relationship between resilience and mental health was found to be 0.35 which gives an indication of its role, whether causative or preventive.[22] The effect of parental style and subsequent resilience of an individual has been found to be of significant importance in various mental health problems. Thus, it is important to study the relationship between perceived parenting style, cognitive style, and resilience for a better understanding of the psychological processes involved in dissociative disorder.

MATERIALS AND METHODS

This was a cross-sectional observational study conducted on adult females with age range of 18–50 years who approached the Department of Psychiatry, Centre of Excellence in Mental Health, PGIMER-Dr RML Hospital for treatment during June 2017–May 2018. Those females who clinically diagnosed with dissociative disorder by the treating psychiatrists were asked to participate in the study. Individuals, who agreed to participate and met the inclusion criteria, were referred to the researcher by the treating psychiatrist while females with any comorbid mental disorder, neurological disorder, substance dependence except nicotine dependence, and those not living with their parents since childhood were excluded from the study. These individuals were explained the purpose of the study and its associated aspects following which written informed consent was taken. The study approval and ethical clearance were taken from the Institutional Review Board and the Institutional Ethics Committee, respectively, of the hospital.

Consenting participants were interviewed. The cognitive styles of the participants were assessed using the Cognitive Styles Inventory (CSI). The perceived parenting style was assessed using short-EMBU (My Memories of Upbringing), after which their resilience was assessed using the Connor's and Davidson's Resilience Scale.

Instruments used

ICD-10 criteria for the diagnosis of dissociative disorder: “Partial or complete loss of the normal integration between memories of the past, awareness of identity, immediate sensations, and control of bodily movements” with no evidence of physical disorder to explain the symptoms and clear temporal association with stressful events (ICD-10, 2006)[23]

Sociodemographic pro forma: A pro forma was created to enter the details of the individuals willing to participate in the study

CSI:[24] Developed by Praveen Kumar Jha (2001) measures the ways of thinking, judging, remembering, storing information, decision-making, and believing in interpersonal relationship. It consists of 40 items which measure systematic-cognitive style and intuitive-cognitive style consisting of 20 items each on a five-point Likert format. Five responses categorized as totally disagree (1), disagree (2), undecided (3), agree (4), and totally agree (5). The minimum and maximum score on both dimensions range from 20 to 100. Reliability of the test was determined by two methods, namely, split-half and test-retest method. The full-length split-half reliability of CSI was 0.653 and for systematic, intuitive, integrated, undifferentiated, and split cognitive styles are 0.83, 0.78, 0.73, 0.76, and 0.70, respectively[24]

Connor and Davidson's Resiliency Scale:[25] It is a 25-item scale developed by Connor and Davidson (2003) to measure resilience. It uses a five-point Likert scale response format ranging from zero (”not true at all”) to four (”true nearly all the time”), with a total score ranging from 0 to 100. The Hindi version of the scale was translated and validated by Kamlesh Singh (2010). Item-total score and factor analysis were used to determine the validity of the scale which came out to be 0.76. The reliability coefficient, as calculated by Cronbach's alpha was 0.83

Short-”My Memories of Upbringing” (s-EMBU):[26] A measure of perceived parental rearing behavior consisting of three scales “Rejection, Emotional Warmth, and Protection” with, respectively, 7, 6, and 9 items plus 0 unscaled item was developed from the original 81-item version. The internal consistency coefficients Cronbach's alphas were of high magnitude (>0.72). As this scale was not available in Hindi, it was translated in Hindi and back translated in English as per the criteria for translation and was face validated by three experts.

Statistical analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS), Version 20 (IBM Corp, NY, USA).[27] The descriptive statistical analysis was carried out and results on continuous measurements are presented as mean ± standard deviation (SD) in the table, while results for the categorical measurements are presented in frequency and percentages (%). Shapiro–Wilk was conducted to assess the normality of the data. For determining the relationship between the variables, the Spearman rank correlation was done.

To establish whether mediation analysis can be performed, linear regression analysis was done between variable X (perceived parental style) and variable Y (resilience) and between variable X (perceived parental style) and variable M (cognitive style). A significant finding could not be obtained between variable X (perceived parental style) and variable Y (resilience), thus mediation analysis could not be performed. Mediation analysis could not be conducted as all four assumptions were not fulfilled.

RESULTS

Results of the current study revealed from 60 females with dissociative disorder that the mean age of the participants was 28 years with average years of formal education being 10 years. They were mostly from a joint family with urban background. Predominantly, they presented with symptoms of dissociative stupor (31.7%), dissociative convulsion (28.3%), and trance and possession (13.3%). Other manifestations were in the form of amnesia, mixed dissociation, aphonia, and not otherwise specified according to the diagnostic criteria of ICD-10 [Table 1].

Table 1

Frequency of type of dissociative disorder (n=60)

Type	Frequency (%)
Stupor	19 (31.7)
Convulsion	17 (28.3)
Possession	8 (13.3)
Not otherwise specified	5 (8.3)
Mixed	4 (6.7)
Amnesia	3 (5.0)
Motor	2 (3.3)
Aphonia	1 (1.7)
Unspecified	1 (1.7)

Correlation analysis was done using the Spearman rank correlation to assess the relationship between rejection, emotional warmth, overprotection perceived parental style, and resilience. A Spearman's correlation was run to assess the relationship between rejection, emotional warmth, overprotection perceived parental style and systematic-cognitive style, and between rejection, emotional warmth, overprotection perceived parental style, and intuitive-cognitive style. Thereafter, the Spearman's rank correlation was again conducted between systematic-cognitive style and resilience and between intuitive-cognitive style and resilience. A significant positive relationship was obtained between emotional warmth and systematic-cognitive style (rs= 0.398, P = 0.01) as well as between systematic-cognitive style and resilience (rs= 0.256, P = 0.05). This indicates that the more emotional warmth was perceived by the participants, the more systematic they were in their perception of the environment, in turn being more resilient [Figure 1].

Figure 1

Correlation between perceived parental style, cognitive style, and resilience. *Correlation is significant at the 0.05 level (two-tailed), **Correlation is significant at the 0.01 level (two-tailed)

A simple linear regression was calculated to predict systematic-cognitive style based on emotional warmth as the perceived parental style. The scatterplot showed that there was a strong positive linear relationship between the two, which was confirmed with Spearman's correlation coefficient of 0.369. A significant regression equation was found (F(1, 58) = 9.146, P < 0.004), with an R2= 0.136. Participant's cognitive style increased 1.682 points for each point of emotional warmth. This suggests that emotional warmth leads to and fosters systematic-cognitive style [Table 2].

Table 2

Regression analysis of emotional warmth and systematic-cognitive style

Systematic-cognitive stylea	B	SEB	β	t	P
Emotional warmthb	1.682	0.556	0.369	3.024	0.004**

**Correlation is significant at the 0.01 level (two-tailed), aDependent variable: Systematic cognitive style, bPredictors in the model: Emotional warmth. SE B – Standard error of unstandardized Beta

A simple linear regression was calculated to predict resilience based on systematic-cognitive style. The scatterplot showed that there was a strong positive linear relationship between the two, which was confirmed with Spearman's correlation coefficient of 0.306. A significant regression equation was found (F (1, 58) = 6.006, P < 0.017), with an R2= 0.094. Participant's cognitive style increased 0.320 points for each point of emotional warmth. This finding depicts that systematic-cognitive style leads to greater resilience [Table 3].

Table 3

Regression analysis of systematic-cognitive style and resilience

Resiliencea	B	SEB	β	t	P
Systematic-cognitive styleb	0.320	0.131	0.306	2.451	0.017*

*Correlation is significant at the 0.05 level (two-tailed), aDependent variable: Resilience, bPredictors in the model: Systematic-cognitive style. SE B– Standard error of unstandardized Beta

Four assumptions were required to be fulfilled to do mediation analysis. First, the causal variable (perceived parental style) is correlated with the outcome (resilience). Second, the causal variable (perceived parental style) is correlated with the mediator (cognitive style). Third, the mediator (cognitive style) is correlated with outcome (resilience). Fourth, the effect of causal variable (perceived parental style) on the outcome (resilience) controlling for the mediator (cognitive style) should be zero. As the first assumption was not met, it could not be conducted [Figure 1].

DISCUSSION

The results stated above shed light upon the role of perceived parental styles, cognitive styles, and resilience in females with dissociative disorder. For this study, perceived parental style was the predictor variable (X), cognitive style was the mediating variable (M), and resilience was the outcome variable (Y). In the present study, the age of the participants ranged from 18 years to 50 years (n = 60), with a mean age of 27.77 years (SD = 1.274). Average number of years of formal education was 10.43 (SD = 0.603). Ninety percent of the participants were from an urban background. There was no significant difference in the family type of the participants, 60% were from joint family and 59% from nuclear family and 1% was living away from the home. Studies examining the relationship between early parental interactions and later psychopathology provide some evidence that parenting styles characterized by overprotection and low warmth or noncontingent parental responsiveness may have significant influences in the development of psychopathology.[17]

For determining whether a relationship exists between perceived parental style and resilience, the Spearman rank correlation was performed. The hypothesis stating that a relationship between the two variables existed was rejected as a result was not found to be significant. Further regression analysis was also not performed. Contradictory results have been found in this regard in the previous researches. Parenting styles have been related to higher levels of resilience in childhood, adolescence, and even adulthood.[21] Fathers' authoritarian style has been positively related to adolescents' emotion-focused coping; however, this has been disputed by many researches. Opposing findings have concluded that authoritarian and harsh parental styles are closely associated with psychological disturbance.[14] Acceptance involvement style is positively correlated to resilience which is associated with one's perception of the amount of paying attention by the parents and their responsiveness.[21] Individuals with high resilience rate show their relationship with family positively due to acceptance and no cohesion.[28] Theron proposed that resilience provided a protective system encompassing the skills of problem-solving, self-regulation, and reasoning.[29] The absence of parental support since early childhood has also been associated with poor adjustment.[30] Support for the effect of parental style on resilience also comes from Masten and Coatsworth's hypothesis that those whose parents do not show acceptance score low on resilience.[29] Several statistical reasons could have contributed to a lack of relationship, some of them being a nonlinear relationship between the two variables or due to the presence of Simpson's paradox due to excessive uncontrolled variance.[31] One's perception and recall of the parenting styles employed by parents may also be influenced by their current state of mind. In the current study, variables such as age or educational qualification could have affected the results leading to a small correlation coefficient. Previous research and theoretical background strongly suggest that perceived parental style has an effect on an individual's resilience.[1421] However, in the present study, mediation analysis could not be conducted.

Thereafter, the relationship between perceived parental style and cognitive style was assessed using the Spearman rank correlation. The hypothesis stating that a relationship between the two variables existed was accepted as a result was found to be significant. Regression analysis indicated that a predictive relationship exists between emotional warmth and systematic-cognitive style. Emotional warmth includes the behavior of parents characterized by positive affect, responsiveness, and support for children. Constant and consistent exchange with the children helps in the development of problem-solving models in situations of high anxiety.[18] A relationship between personality and psychopathology has been repeatedly been proven, including the role of neuroticism in dissociative disorder. Takahashi et al. concluded that perceived parental affectionless is associated with high neuroticism, thereby indicating an indirect link between affectionless control by parents and dissociation.[32] A link between negative events in childhood and development of dysfunctional cognitive styles has been often proposed.[33] Even though a relationship could not be established between overprotection and rejection, and maladaptive cognitive style in the present study, previous literature suggests that pattern of the bond between the children and parents in the early stages may contribute to depression or anxiety in later life due to the impact of negative cognitive styles.[17] Poor parenting has been found to contribute to depression through its effects of children's beliefs and ways of interpreting experiences.[34] This pattern has been mostly studied in either nonclinical populations or among people with depression or anxiety. However, it is worth noting that dissociation occurs as a result of difficulty in dealing with current stressor or situation which may cause anxiety and discomfort in addition to low mood. It can be extrapolated that the role of parenting is still imperative in determining the type of strategies one uses to acquire and process information.

For determining whether a relationship exists between cognitive style and resilience, the Spearman rank correlation was performed. The hypothesis stating that a relationship between the two variables existed was accepted as a correlation between systematic-cognitive style and resilience was found to be significant. Regression analysis indicated that a predictive relationship exists between systematic-cognitive style and resilience. The relationship between critical thinking and self-confidence has been found indicating that students with greater self-confidence had a more favorable interest in critical thinking.[35] Resilience has been overtime been associated with stress risk vulnerability dimension. The way an individual assesses and perceives the environment and the information being presented influences the way the person deals and adapts to it. The systematic-cognitive style incorporates logical and rational behavior that uses a step-by-step sequential approach to thinking, learning, problem-solving, and decision-making. Using the same measure for assessing cognitive style, Ahangar concluded that systematic-cognitive style was positively correlated with resilience providing support for the present study. This is indicative that problem-solving skills are the most frequently used coping mechanism in times of stress.[1936] Acknowledging that individual difference exists in the appraisal of situations and that further influences the series of actions taken to deal with that situation is imperative for enhancing healthy strategies of dealing with stress.

A significant correlation was found between emotional warmth and systematic-cognitive style and systematic-cognitive style and resilience. Regression analysis thereafter proved a cause-effect relationship between these variables. Three assumptions of a mediation analysis were successfully met. One condition, a significant relationship between the predictor and outcome variable, could not be met. Mediation analysis could not be performed. Previous studies provide preliminary yet crucial evidence for the role of cognitive mediation in the relationship between negative parental styles and adult psychopathology.[3738] However, these have focused more on nonclinical sample, whereas the present study dealt with the clinical population. There has been only one other study by Shah and Waller (2000) which delved into studying this mediating relationship in a clinical adult sample.[17] However, similar study has not been done on females with dissociative disorder.

Resilience has been found to be essential as a protective factor in psychiatric conditions. It helps in moderating the effects of stress and promoted adaptation, thereby aiding a person to flourish in the face of adversity.[39] Lower levels have been associated with vulnerability for developing pathological consequences of adverse environmental events.

Dissociation is a complex phenomenon with no single etiological factor and perceived parental style, cognitive style, and resilience may only play a contributory role.

CONCLUSION

The present study revealed that on linear regression analysis a cause-effect relationship could be established between emotional warmth and systematic-cognitive style and systematic-cognitive style and resilience. The findings shed light on the role that parental style perceived by individuals play in how one perceives the environment and thereby influencing one's resilience. It is imperative to focus on early identification of such vulnerable candidates as well as evaluation of the effectiveness of resilience-based intervention.[40] This study postulates that these identification markers could be evaluated by assessing one's perceived parental style as well as cognitive style.

Limitation and implication of the study

The present study was exploratory in nature as literature review demonstrated no existing study on females with dissociative disorder studying the mediating role of cognitive styles in the relationship between perceived parental style and resilience. Thereby, the conclusions drawn from this study may not be generalizable. Another consideration is that the tools used were all self-report measure; the participants' current state of mind, psychopathology, or motivation could have significantly affected their answers. The construct of perceived parental style itself suggests that it is one's perception and may not be entirely objective. In addition, educational qualification, family type, and marital status were not controlled and may act as confounding variables in this study.

The findings of this study will help pave the path in establishing protective psychological factors of dissociative disorder. A model of healthy and positive parenting style and its effect on cognitive style and resilience can be proposed on the basis of existing literature as well as the findings of our study [Figure 2].

Figure 2

Model indicating healthy parenting styles and its impact on areas of development

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.