Qualitative content analysis of cultural formulations of clients suffering from conversion disorder in North India.

Introduction: Conversion disorder is easily one of the least understood neuropsychiatric disorders. There is a great deal of ambiguity with respect to symptom presentation, assessment, etiology, diagnosis, and treatment. However, a common clinical practice associated with the assessment and management of the conversion disorder is the evaluation of a stressor. Recent studies in India have indicated that family stressors are the most frequent. Sociocultural aspects of the client's environment and the illness experience thus form an important part of the client's diagnostic formulation. These aspects also determine help-seeking, treatment adherence, and thus, the outcomes. Materials and
Methods: Fifteen clients suffering from conversion disorder in a tertiary mental health setting in North India, recruited through purposive sampling, were interviewed in-depth. Data were elicited using the cultural formulation interview (CFI). Qualitative content analysis was carried out.
Results: The content analyses summarized the cultural experiences of clients suffering from conversion disorder under structured domains of the CFI. The results are presented in tables along with content examples and represent individual client experiences and conceptualizations of diagnosis, treatment, and implications of suffering from conversion disorder. The findings of this study aim to describe and highlight the cultural experiences of clients with respect to their psychopathology. The most striking recurrent theme in the cultural formulations were the lack of understanding of the nature and cause of illness both in the client as well as the clinician, and therefore a lack of trust and hope in the treatment.
Conclusion: The findings of the current study shed light on the cultural experiences of clients with conversion disorder. These findings emphasize the need for clinicians to incorporate the individual and collective cultural experiences of clients and cultural sensitivity in addition to the clinical diagnoses. The Cultural Formulation Interview of the DSM-5 was found to be very helpful in this regard and we encourage its use by clinicians, especially with clients suffering from conversion disorder, given the strong influences of socio-cultural experiences on psychopathology as well as the intervention. Copyright:

INTRODUCTION

India is a multi-cultural country which was once divided into fractions of kingdoms. Currently, with 22 official languages, 29 states, 37 heritage sites, and at least 9 recognized religions, it is home to different world cultures and ethnicities. However, culture is a multifactorial set of overlapping systems made up of many components beyond race, religion, and ethnicity and deeply and intricately diffused within societal systems and within the psychology of an individual. Thus, it is important to understand each individual in the light of the culture they come from. The cultural formulation interview (CFI), introduced in the DSM-5, is an interview designed to enhance the cultural validity of the diagnoses.[1] It has four core major domains and encourages patient narratives of an illness from their individual perspectives. It is based on evidence and assists the clinician in enhancing the cultural validity of diagnoses and treatments by helping to make person-centered cultural assessments.

Conversion disorder is characterized by appearance of neurological symptoms like blindness, pseudo-seizures with underlying psychological causes.[2] The conversion disorder is arguably one of the least understood psychiatric conditions. In the National Mental Health Survey, the prevalence for neurotic and stress-related disorders (F40 to F48), lifetime, and current, was recorded to be 3.7% and 3.5%, respectively.[3] The exact prevalence of conversion disorders is thus, unknown. At the National Institute of Mental Health and Neurosciences, Bangalore, in a decade, 893 patients were diagnosed with conversion disorders.[4] In another study of the clinical and sociodemographic correlates in 40 people in Assam, it was concluded that conversion disorder is more common in young adults, females, and in nuclear families of lower socioeconomic status.[5] Stressors in their study were found to be either family or school related-thus, sociocultural in nature. Thus, it becomes important to understand the phenomenological experiences of the clients to inform the theory and practice related to the disorder. The knowledge of sociocultural experiences that contribute to pathogenesis, worsening as well as treatment of the symptoms is important to enhance the effectiveness of psychological interventions in these clients.

Aim

The purpose of the present study was to describe the sociocultural formulations of individuals with conversion disorder using the CFI.

MATERIALS AND METHODS

Setting

The study was conducted in the outpatient clinical psychology department of a tertiary neuropsychiatric governmental hospital offering free services. The hospital is based in a metropolitan city of historical and cultural value and attracts clientele in huge numbers from neighboring states.

Tools

The core CFI of the DSM-5 is a 16-item semi-structured interview designed for use with patients. The Hindi translated version of the CFI, obtained from the Dr. Ram Manohar Lohia Hospital, Delhi, has 14 items. Since the majority of population is Hindi speaking, this translated version was used for the current study with due permission.

Sample

The target population for this study was defined to include the clients diagnosed with Conversion disorder in North India, while the accessible population was the individuals having a diagnosis of Conversion disorder or dissociative disorder (as per International Classification of Diseases-10) and attending the outpatient department (OPD) in a tertiary hospital in North India between February 2018 and May 2018. Ninety patients were screened – of which a sample of 15 was selected through purposive and convenient sampling from OPD.

Inclusion and exclusion criteria

It was decided to include adult clients with:

Clinical diagnosis of conversion disorder as per the clinical team/case record file

Fluency in Hindi.

And exclude those with:

Presence of a comorbid diagnosis of any severe mental illness or psychosis and organic/neurological diagnosis including seizure disorder and psychosocial disability

Intellectual functioning below average or impaired as per clinical judgment

Clients with acute stress or emotional crises at the time of the interview.

Research design

The present study aims to study the experiences of client and is a qualitative descriptive research. Neesgard et al.[6] have described the advantages of using a qualitative descriptive design in researching patient experiences.

Data analysis

The measures of central tendency were used for descriptive analysis of the sociodemographic data. The qualitative analysis was also done manually in the MS Excel spreadsheet. Qualitative analysis was done using content analysis. Initial categories into the framework were derived from the structure of the instruments (i.e., questions of the CFI). The entire dataset was also read to code content from those questions of each domain that was relevant for other questions or domains, remaining aware of the possibility that a client’s response to any one question might be more relevant to the interests of another question.[7] Constant comparison method[8] was used for the same as the researcher looked for patterns, associations, clustering, and explanations.

Procedure

After familiarizing herself with the CFI using detailed discussion of initial 2–3 cases with the team (guide and co-guide), the researcher conducted the interviews. For data collection, 90 clients referred to clinical psychology (82 females, 8 males) were contacted for participation and subjected to screening, of which 55 met inclusion and exclusion criteria. Eight clients refused to participate while it was not feasible for 22 clients to participate, 8 clients dropped out and 2 interviews were scrapped because of not understanding the subject of the interview. The process finished with 15 completed interviews.

Ethical considerations

The ethics committee of the institute approved the study. Briefing sessions were held and the research was explained to each client and their informants. Information sheets with details of the research and the researcher were provided to each person and thus written as well as verbal informed consent was obtained from the participants. Confidentiality of identity and information provided by the client was maintained and the same was communicated in the informed consent sheet. The consent form was based on the format of the consent form used by Dr. Ram Manohar Lohia Hospital with permission. Separate consent, both written and verbal, was taken with regard to audio recording of the interview. Regular service provision was ensured, and care was taken to continue the treatment of the client as usual.

RESULTS AND DISCUSSION

The study included 15 screened clients who were all women aged 18–40 years [Table 1] with a mean age of 27.6 years (standard deviation of 7.85). Education ranged from 5th Std. to Graduation. Six of 15 participants were unmarried and 4 of the participants were from the Lower socioeconomic status while the other 11 belonged to the middle socioeconomic status. There was comorbid depression in 4 clients, and panic attacks in 2 clients. Family history of seizures had been reported by 4 of the 15 participants. Family setting was majorly nuclear (8/15), joint (6/15), while one client resided with an extended family. Categorically, stressors for all the 15 out of 15 clients involved their family or in-laws, out of which the unmarried 4 women had primary stress in academics or their respective occupations in the form of overload.

Table 1

Sample characteristics and sociodemographics

Sex	Age	Education	Occupation	Marital status	Religion
Female	37	Graduation	Beautician	Married	Hindu
Female	38	8th standard	Homemaker	Married	Hindu
Female	30	8th standard	Self-employed	Married	Hindu
Female	23	12th standard	Unemployed	Unmarried	Hindu
Female	25	10th standard	Homemaker	Married	Hindu
Female	18	11th standard	Student	Unmarried	Hindu
Female	25	8th standard	Homemaker	Married	Hindu
Female	18	11th standard	Student	Unmarried	Hindu
Female	22	Diploma	Student	Unmarried	Hindu
Female	40	8th standard	Homemaker	Married	Hindu
Female	21	Graduation	Student	Unmarried	Hindu
Female	20	Graduation	Student	Unmarried	Hindu
Female	29	5th standard	Homemaker	Married	Hindu
Female	28	Graduation	Homemaker	Married	Sikh
Female	40	10th standard	Homemaker	Married	Muslim

The first domain of the CFI assessed the concerns that the client presented with, the name given to the illness and the most troubling aspect or concern of the illness. Four of 15 participants in the study complained of chronic white vaginal discharge without any gynecological or medical explanations. Leukorrhea is a frequently culturally shared expression of distress amongst women, comparable to the Dhat syndrome in men.[9]

The names used by the participants to explain their illnesses were: “Nass ki problem” (problem of nerves), fits, “Mirgi ke daure” (epilepsy), “Behoshi” (loss of consciousness), paralysis, typhoid fever, “Upri Chakkar” (Evil forces), “fight,” “mind divert,” tension, “Gussa” (anger), depression, anxiety, and “Ghutan” (suffocation). Paralikar et al.[10] in India interviewed participants with varied diagnoses and presented a variety of phrases to name the illness. A primary symptom or an interpersonal issue was also used as names by 7 and 3 out of 36 participants, respectively. Names used were such as mental illness, mental weakness, depression, trouble, tension, and attack.

Table 2 summarizes the most troubling aspects of the illness for the participants. They have been divided into biological, psychological, and social aspects. Although most troubling aspects have not been reported earlier, Dickinson[11] has expounded the internal struggle of the individual with conversion symptoms and the two themes underlying the troubling aspects of the illness experience were loss of control and an inability to communicate.

Table 2

Most troubling symptoms summarized

Content	Categories and themes
Biological/bodily
Piercing pain in the head/chest	Pain
Pain due to movements
Constant dizziness	Loss of control over breathing
Physical weakness
Blurring of vision
Involuntary movements
Involuntary screams	Loss of control over bodily functions
Psychological
Excessive anger	Emotional dysregulation
Tension
Uncontrollable crying
Inability to tolerate critical comments by others	Sensitivity to criticism/rejection
Inability to recall	Cognitive symptoms
Out-of-the-blue episodes/outbursts	Unpredictability
Social
Conflicts with significant others	Interpersonal stressors
Behavior of others towards the client
Dismissing of illness by significant others	Stigma and attitude towards illness
Shame and embarrassment due to episodes

The second domain [Tables 3 and 4] assessed the perspectives of the participant and their culture on the causes of illness or explanatory models as well as the stresses and supports present in the environment. It also assessed the perception of the impact of cultural identity on the participant’s current life situation. The perceived ambiguity about the cause of illness as experienced by the participants extended to the doctors and helping professionals who thought that the doctors have not diagnosed the problem-some even concluded that they have a dangerous disease which has not been diagnosed because science has no knowledge of the disease they are suffering from. They also concluded that their treatment will be ineffective due to nonunderstanding of the diagnoses. Extensive literature is available on as to what the clients attribute their illnesses too. Sumathipala et al.[12] organized the causes of conversion disorder in Sri Lankan patients as per the perceived space of the individual – organizing the causes into internal, social, natural, and supernatural worlds. Many participants, however, were unable to outline any specific cause for their illness. The advantage of the in-depth cultural interview in the current study was that the causes were expressed directly or indirectly, on or without probing – by the end of the interview. Clients with chronic conversions attributed their stress to burden of multiple hospital visits and dismissing attitude of clinicians and relatives towards them. Majority of the stressors were family related, and this is consistent with previous literature.

Table 3

Perceived causes of illness and contextual stressors summarized

Content	Categories and themes
Biological
Leukorrhea, skipping of menses, thyroid fever	Physical illnesses
Physical strain causing weakness, multiple abortions, early child-bearing and rearing, blood/Vitamin deficiencies	Physical weakness
Medicines causing excessive heat in body	“Body heat”
Induction of episode when nerves are pressed, headache and lack of sleep, brain damage due to events of fall, traumatic hits to the head, heat of medicines in brain	Neurological causes
Traditional-cultural
Spirit entering the body	External evil forces
Psychological
Excessive anger towards others, stress about illness not being diagnosed, work-related stress, inability to let go of critical comments	Emotional dysregulation
Being unable to tell anyone how she feels	Inability to express emotions
Continuously thinking about stressors	Cognitive causes
Social
Hitting and abuse by family members	Domestic violence
Critical comments by family members, ill-treatment by doctors, being accused of faking symptoms	Stigma
Loss/lack of support from parents, friends, loneliness, no help in household work	Perceived lack of social support
Fights with, among family, lack/invasion of privacy and autonomy, when family members are disturbed, when husband/in-laws are disappointed	Interpersonal stress
Loud noises, due to heat, excessive screen exposure	Excessive stimulation
Failure in 10th/12th exams, being unable to carry out household work, excessive burden of household chores, studying too much, financial strains	Occupational stressors
Miscellaneous
Does not know why	Uncertain

Table 4

Aspects of cultural identity summarized

Categories	Negative impact on identity-frequencies	Positive impact on identity-frequencies
Personal/microsystem
Gender	4	4
Art and literature	0	8
Education	5	5
Employment	1	3
Family	6	4
Marriage/in-laws	5	3
Meso- and exosystem
Social status	3	2
Caste	3	4
Social relationships, groups	0	1
Neighborhood, locality, society	1	4
Religion	1	4
Macrosystem
Politics	2	0
Traditions, values, customs	1	1
Chronosystem
Migration	1	4
Victimization	3	0

n=15, n=36 for negative, 47 for positive

The perception of support in the current study was noticeably limited. Many clients responded with a nil answer to this question. Of the kinds of support, interpersonal support was stated spontaneously by only a few clients and involved communication with others or receiving acknowledgment and attention from significant others. Most of them expressed support available in the form of emergency medicine/doctors. Kim and Zane[13] had reviewed that the willingness and support-seeking behaviors may reliably and consistently vary across cultures. For e.g., they had stated that Asians and Asian-Americans were less willing to seek support as compared to European Americans.

The question of cultural identity was not easily understood by all, and some (6 participants of 15) straightaway denied the possibility of negative effects of aspects of their cultural identity in life. However, on probing, 4 of 6 clients reported at least 2 aspects of cultural identity that had negative impacts on their life [Table 4]. The themes obtained in the current study were derived from the ecological systems theory of Bronfenbrenner (1979),[14] that structured the environment into microsystems-layer closest to the individual, mesosystem, and exosystem comprising larger sociocultural elements with which the individual does not have a direct contact, macrosystem – comprising cultural values and chronosystem – referring to significant life events or other time elements.

The third domain [Tables 5-7] assessed cultural factors affecting self-coping and past help-seeking. Coping methods majorly engaged in by participants were categorized as emotion-focused coping and problem-focused coping. Problem-focused coping was used less frequently. Brown and Reuber[15] indicated evidence to show that clients with conversion disorder have increased emotion-focused coping and diminished problem-focused coping.

Table 5

Coping strategies summarized

Content examples	Categories and themes
Traditional/cultural
“My parents take me to the temple” “They perform some rituals on me to make it go away”	Alternative healing methods
“I read the Namaaz at that time”; “I go to the temple and feel better”	Religious coping
Biological/medical
“I take my medicines from time to time” ; “There is a tablet to help with weakness, I take that” “I take Glucon D for physical weakness” “They give me I.V. fluids/injections”	Medicines/supplements
“I go for a walk every evening”; “I have joined Yoga class”	Physical exercise
Problem-focused coping Problem-solving/active coping
“I speak with my husband about the matter”; “I search for a solution to our conflict” “I think about what I did wrong”	Resolution of conflicts
“I have been to a counsellor and it has helped”	Psychological therapies
Emotion-focused coping Behavioral disengagement
“I listen to music with my earphones on” “I go and get fresh air”	Recreational activity
“I just make sure I complete all my work on time” “I forget all of this and sit to study”	Occupational activity
“I immediately go to sleep” ;“I try to forget whatever happened” “I just do not want to talk to anyone then”	Relief from stressors
“Dr. had shown me deep breathing exercise” ; “I concentrate and meditate”	Meditation and relaxation
Ventilation
“I talk on the phone with my sister”; “I seek advice of my tuition teacher”	Seeking social support
“I feel better after crying”; “I try to write a diary”	Emotional venting

Table 7

Barriers to help-seeking summarized

Content examples	Basic themes
Social barriers
“They call it the mental hospital” “They think I am faking and have no illness”	Stigma
“There was no-one to go with me to the hospital”	Caregiver/companion
Resource constraints
“The charges were too much” “traveling costs”	Finance
“I have 3 children to take care of when I return from here”	Time
“We had no idea that this was a psychiatric illness”
“I did not know there was treatment for my anger?	Lack of awareness
Illness-related
“I am unable to travel alone due to fear of collapsing”	Impairing symptoms
“I have seen no improvement in many years, what do I say I go to hospitals for?”	Anticipation of treatment/outcome
Institutional barriers
“The window closed at 11 am and we arrived later”	Hospital formalities

In past help-seeking, traditional cultural methods were often the first route to treatment for the sample in the current study. Fourteen of the 15 clients had been through the traditional cultural methods, and all but two participants reported that such treatment was ineffective. It was noticed that many participants rated the usefulness of the treatment according to the demeanor of the doctor and were quite communicative about it. The importance of traditional healers in the Indian society has been widely described.[1617] Psychiatric or other medicines were seen as the most helpful help-seeking method by most participants (n = 9) while also being the least helpful method for a lot of participants (n = 5). A majority of the clients reported being misdiagnosed with epilepsy at some point in time, and thus, the treatment-seeking would usually oscillate between medicine and neurology before a referral was finally made to a psychiatric hospital. Due to lack of awareness, especially in remote areas and in other health professionals, this gap period for some clients before receiving psychiatric intervention was in some cases as long as 5–10 years. The waiting period was higher for a client to have received psychological intervention. Literature has also suggested that most patients with psychogenic nonepileptic seizures are initially misdiagnosed as having epilepsy.[18]

Barriers to seeking treatment in the past are summarized in Table 7 and include constraint of personal resources, illness and treatment-related barriers, lack of awareness and stigma, lack of support to go to hospital with, and institutional barriers such as excessive hospital formalities. Smith and Jozefowicz[19] in their review have pointed out the problems as time taken for diagnosis, reduced communication between caregivers, referrals to (numerous) unknown caregivers, lowered confidence in cure, extent of time before initiation of therapy after diagnosis, and lack of patient engagement and retention.

The fourth domain assessed the cultural factors affecting current help-seeking. In 3 chronic cases of conversions of nonepileptic seizures, the participants explained the chronicity as a result of misdiagnosis or inability of the “doctors” in understanding their illness. However, upon further discussions outside the interview, maintaining factors in these cases were assessed to be interpersonal issues in the family, stress related to illness and treatment as well as secondary gains associated with illness. It has been seen that the treatment satisfaction of such clients is very low and hence they tend to resort to alternative healing methods. This has been highlighted in the literature repeatedly. Desai and Chaturvedi[9] have emphasized that there are “cultural blind spots in clinical practice.” Most participants denied the effects of cultural disparity between the client and the clinician on the treatment. Language and gender differences were pointed out by some clients as hurdles in expression. Lack of personal affiliations with the clinician was seen to be an obstruction in seeking help as preferences were not given to clients. The personal affiliations in Indian cultures are many times based on socioeconomic status, caste, and religion. Thus, in a government hospital setting catering to a large population, lack of personal affiliations, cultural disparity may be seen as a disadvantage. Bogo et al.[20] have summarized the effects of cultural differences in client and clinician-they explain that overt differences may lead to lack of familiarity and comfort in clinical communication and hence in the establishment of therapeutic alliance. The clinicians may also find it difficult to understand and empathize with the unique cultural experiences of the client making it highly likely that the clinical communication is restricted to “culturally neutral” elements.

On the question of help desired by participants, many of them requested for clear communication and explanation of diagnosis or to provide them a “name of their illness.” They also requested scans and investigations, with emphasis on brain scans to clarify the diagnosis. Psychiatric medicine and Psychotherapy were also sought by many clients, while some requested for “no medicine” due to fear of side effects. Clear explanations are desperately sought by patients and are thought to be key to eventual recovery.[21] Communication of diagnosis is seen in the literature as in important process in the diagnosis.[21] However, the strategy was seen as equally important as clients are often reluctant to explain nonphysical explanations of their symptoms.

The current study explored and reported sociocultural formulations of clients with conversion disorder. The study is the first one to use the Cultural Formulation model of the DSM-5 to assess the cultural experiences of a specific clinical group. The findings of the study provide a window into the sociocultural formulations and experiences of women with conversion disorder using a framework. These findings may help in developing or culturally adapting psychological interventions for women with conversion disorder. The limitations of the study are: The study sample was limited to the geographical sample of North India, and also, the sample consisted only of women. Methodologically, triangulation of methods could not be done using other qualitative and/or quantitative methods. Overall, the interview was able to elicit rich data, and the results are important in order to understand how clients experience and cope with the disorder. This also speaks to the utility of the CFI in clinical practice and its depth in assessing socio-cultural formulations of psychopathology. The CFI may also prove useful in research, since it lends a framework for sociocultural formulations. Future studies can explore patterns of cultural formulations in different disorders and in different cultures.

CONCLUSION

Conversion disorder is a difficult diagnosis to deal with due to its ambiguity, diagnostic difficulty, and the reactions of the doctors and family members of the client. With the advent of the client-centered perspective in mental health practice, it is considered important to incorporate in each case-the client’s perceptions and expectations into the clinician’s formulation and management plan. The meaning of illness in client’s mind has direct links with the perceived outcomes. Even the health-belief model emphasizes the role of perceived severity of illness as an important factor in determining help-seeking behavior. In summary, the case formulation of a clinician, however perfect in its technicalities, may not be complete if it fails to factor in the idiosyncratic sociocultural worlds of the client in which they place themselves and the illness.

In the backdrop of this, the present study had evaluated the sociocultural formulations of clients with conversion disorder. The content analysis described a variety of categories under which clients with conversion disorder conceptualize their illness. The explanatory models of the client and their closed ones have been described. Clients’ dissatisfaction with the diagnosis and treatment has been observed to be a repeated theme along with significant barriers in seeking help. The need for cultural sensitivity in clinical practice is emphasized, especially in the context of conversion disorder, given its heavy sociocultural influences. The CFI of the DSM-5 offers rich insights into these aspects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 6

Past help-seeking summarized

Codes and categories	Most useful-frequency	Least useful-frequency
Traditional-cultural	2	3
Medical	9	5
Problem-focused coping	2	-
Emotion-focused coping	1	-