Marital adjustment of patients with substance dependence, schizophrenia and bipolar affective disorder
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.126316
Background: Marital adjustment is considered as a part of social well-being. Disturbed marital relationship can directly affect the disease adjustment and the way they face disease outcomes and complications. It may adversely affect physical health, mental health, the quality-of-life and even economic status of individuals. Aim: The aim of this study was to compare the marital adjustment among patients with substance dependence, schizophrenia and bipolar affective disorder. Materials and Methods: The sample consisted of each 30 patients with substance dependence, bipolar affective disorder and schizophrenia, diagnosed as per international classification of diseases-10 diagnostic criteria for research with a minimum duration of illness of 1 year were evaluated using marital adjustment questionnaire. The data was analyzed using parametric and non-parametric statistics. Results: Prevalence of poor marital adjustment in patients with schizophrenia, bipolar affective disorder and substance dependence was 60%, 70% and 50% respectively. There was a significant difference on overall marital adjustment among substance dependence and bipolar affective disorder patients. There was no significant difference on overall marital adjustment among patients with substance dependence and schizophrenia as well as among patients with schizophrenia and bipolar affective disorder. On marital adjustment domains, schizophrenia patients had significantly poor sexual adjustment than substance dependence patients while bipolar affective disorder patients had significantly poor sexual and social adjustment compared with substance dependence patients. Conclusion: Patients with substance dependence have significant better overall marital adjustment compared with bipolar affective disorder patients. Patients with substance dependence have significantly better social and sexual adjustment than patients with bipolar affective disorder as well as significantly better sexual adjustment than schizophrenia patients. Keywords: Bipolar affective disorder, marital adjustment, schizophrenia, substance dependence
Marriage and family meet man's deepest needs for companionship, affection and sexual expression. It involves the most intimate type of emotional relationship between two individuals. Marital adjustment is defined as, "the state in which there is an overall feeling between husband and wife, of happiness and satisfaction with their marriage and with each other." [1] It, therefore, entails experiencing satisfactory relationship between spouses characterized by mutual concern, care, understanding and acceptance. Marital adjustment is considered as a part of social well-being. Disturbed marital relationship adversely affects physical health, mental health, the quality-of-life and even economic status of individuals. [2],[3] For several patients with chronic illnesses, marital relationship is a serious concern. It can directly affect the disease adjustment and the way they face disease outcomes and complications. [4],[5] In general, there is a well-established association between marital status and individual psychopathology. Epidemiological data suggest that married individuals are less likely to suffer from a psychiatric disorder than those who are separated or divorced. In addition, men and women who are married have a lower rate of presentation to out-patient mental health services and are less likely to be admitted to a psychiatric hospital. It is not the case that simply being married offers protection against developing a psychological disorder. Men and women in satisfying marriages definitely have a lower risk for psychiatric disorder than other segments of the population. [6] On the other hand, couples in an unhappy marriage, the relationship can cause significant stress with related health consequences-most frequently, chronic, diffuse physiological arousal that manifests in physical ailments including high blood pressure, heart disease, anxiety, depression, suicide, violence, psychosis, homicide and substance abuse. [7] There is growing literature linking marital dissatisfaction with the onset, course and treatment of adult psychiatric disorders. Although a strong association has been reported between marital problems and psychopathology by numerous researchers, the causal connection remains uncertain. Several studies indicate that marital discord may have a causal effect on psychological disorders [8],[9],[10] while other studies suggest that psychological disorders play a causal role in creating and maintaining disrupted marital interactions. [11],[12] Finally, some research indicates that marital problems and psychological disorders reciprocally influence one another. [6] There is a strong association reported between alcohol abuse and marital distress. A study using data from the National Comorbidity Survey (NCS) [13] found greater marital dissatisfaction was associated with alcohol dependence for men. [12] In another study, one-third of couples presenting with the marital problems reported alcohol abuse in the male partners and over three-quarters of couples reported frequent disagreement regarding alcohol consumption. [14] Numerous studies document that both men presenting for alcoholism and their partners report low relationship satisfaction, frequent and intense arguments, poor sexual functioning, higher levels of maladaptive marital interaction patterns and higher levels of marital violence. [15],[16],[17] Furthermore, observational studies have identified noticeable deficits in problem solving and communication skills in couples, in which one partner is a problem drinker. In particular, couples in which one partner has an alcohol problem are characterized by high rates of verbal and non-verbal negative affect expression, few supportive and constructive responses and male withdrawal during the conflicts. [18] Whisman [12] examined the association between marital dissatisfaction and 12-month prevalence rates of common axis I psychiatric disorders in married respondents from the NCS. Results indicated that spouses with any disorder, any mood disorder and any anxiety disorder reported significantly greater marital dissatisfaction than spouses without the corresponding groupings of disorders. The clinical features of bipolar disorder have an impact on intimate relationship, quality of relationship and on the outcome among bipolar patients. Radke-Yarrow et al. [19] interviewed bipolar women in a study of offspring and family interactions. She found that women with bipolar affective disorder (a mix of bipolar I and II) reported higher rates of marital disorder at all follow-up assessment (62-76%) compare with non-ill women (7-13%) or women with unipolar depression (53-59%). Although the marriages of individuals with psychosis have not been studied extensively, there appears to be a strong association between psychosis and marital status. Individuals with a psychotic disorder are less likely to marry than the rest of the population. Some of the difficulties may include coping with severely disturbed behavior during periods of acute psychotic episodes, disrupted household routines (e.g., as the result irregular sleeping and eating patterns and self-care), inappropriate interpersonal behavior, social withdrawal and emotional unresponsiveness. [6] In view of the paucity of Indian studies in this field, the present work was undertaken to assess the level of marital adjustment and to compare marital adjustment among patients with substance dependence, schizophrenia and bipolar affective disorder.
Settings and Design This cross-sectional study was carried out on indoor and outdoor patients of Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS), Ranchi. Ethical clearance for the study was obtained from the Institutional Ethical Committee. Sample The sample consisted of each 30 patients with substance dependence, schizophrenia and bipolar affective disorder, based on purposive sampling technique, from out-patient and inpatient department of RINPAS, Ranchi. All patients of substance dependence were dependent on alcohol and were not abusing any other substance apart from nicotine. None of patients with schizophrenia and bipolar disorder had comorbid substance abuse or dependence apart from nicotine. Patients were diagnosed as per international classification of diseases-10 diagnostic criteria for research criteria. [20] The three groups were age and sex matched. The age range of the sample was 20-50 years. Patients with other comorbid psychiatric disorders or physical disorders were excluded. Tools Socio-Demographic Data Sheet: Socio-demographic data sheet was used to collect details such as sex, age, education, occupation, monthly income, religion, domicile and family type, course of illness and duration of illness. Marital adjustment questionnaire (MAQ): [21] It consists of 25 highly discriminating "yes-no" type items. According to this questionnaire, the higher the score, better is the adjustment There are three domains given as sexual (item 9, 20, 23, 25), social (item 3, 4, 5, 6, 12, 14, 15, 18, 19) and emotional (item 1, 2, 7, 8, 10, 11, 13, 16, 17, 21, 22, 24). The split-half reliability, correlating odd-even items, applying the spearman-brown formula for doubling the test length, was found to be 49 (N = 60) with an index of reliability of 70. The face validity of the questionnaire appeared too high. The questionnaire was validated against Singh's marital adjustment inventory and was found to be 0.71 with the index of reliability of 0.04. Procedure Patients were initially interviewed to collect the socio-demographic data. The researcher explained the study to all subjects and informed consent was obtained prior to completion of the questionnaires. Thereafter, the MAQ was administered individually to patient. The questionnaires were scored as per the test manual and the data was tabulated and analyzed. Statistical Analysis The statistical analysis was performed by using the SPSS (IBM Corp.) program. Parametric test were used for continuous data and non-parametric tests were used for ordinal data.
Age of the patients included in the study is shown in [Table 1]. There was no statistically significant difference in the mean age of the three groups of the patients [Table 2].
Socio-demographic and clinical characteristics of the sample are given in [Table 3]. Majority of the respondents in all three groups were from age group of 31-50 years, educated up to secondary, employed, Hindu, with a rural background. In clinical characteristics, majority of the respondents had episodic course of illness and up to 4 years duration of illness. Distribution of patients according to quality of marital adjustment is given in [Table 4]. Poor marital adjustment was observed in 70% of patients with bipolar affective disorder, 60% of schizophrenia patients and 50% of patients with substance dependence.
[Table 5] shows total and domain wise score on marital adjustment. To analyses the differences in score on marital adjustment with domain wise score between trees groups of patients, Mann-Whitney U-test was performed [Table 6]. Result showed that the total score on MAQ of substance dependence patients was significantly more than schizophrenia (P = 0.039) and bipolar affective disorder patients. There is no significant difference noted between patients with schizophrenia and bipolar affective disorder on overall marital adjustment. Scores obtained by three groups of patients in the three domains of MAQ were also compared. The result showed a significant difference in sexual adjustment domain among patients with substance dependence and patients with schizophrenia and bipolar affective disorder. There is also significant difference found on social adjustment domain among patients with substance dependence and bipolar affective disorder. There is no significant difference found among three groups on emotional adjustment domain. This indicates that the difference in the marital adjustment score between substance dependence patient's and bipolar affective disorder was mainly due to differences in the sexual and social adjustment domain.
The main finding of the present study is that the majority of patients from the three groups (substance dependence, schizophrenia and bipolar affective disorder) have poor marital adjustment. There is a significant difference found on overall marital adjustment among patients with substance dependence and bipolar affective disorder, which indicates that substance dependence patients have better marital adjustment quality than patients with bipolar affective disorder. There is no significant difference found on marital adjustment among patients with substance dependence and schizophrenia and among schizophrenia and bipolar affective disorder patients. It can be concluded that patients with bipolar affective disorder and schizophrenia have more or less similar marital adjustment level and that is poor marital adjustment. Substance dependence patients have somewhat better marital adjustment level than these two groups (schizophrenia and bipolar affective disorder). These findings are broadly in agreement with the findings of earlier studies. [6],[8],[11],[12],[15],[22] It must be emphasized here that the results must be interpreted with caution due to the nature of the illness of the patients. Individuals with substance dependence are more likely to have a pattern of conduct marked by impulsivity, weak resistance to frustration and focus on personal needs, schemes of attribution based on external locus of control and focus on personal and immediate needs. This may lead subjects to underestimate the impact of their conduct in family and marital relationships. It may also lead to a bias in own evaluation of their marital role. On the other hand, due to the effect of negative symptoms and lack of insight schizophrenia patients may undervalue their role as husband/wife and the impact of the illness. However, because of the tendency to social withdrawal, their partners may tend to replace the role as a spouse by a role as a caregiver and by this mitigate the degree and frequency of negative interactions in the marital context. In contrast to the above, Bipolar patients tend to have a better global functioning between crisis; this may represent a higher level of expectations regarding the role as a spouse and a stronger impact of the illness both for the spouse and for the patient and by this way, a more realistic and more emotionally charged evaluation of the marital relationship. The above findings are not surprising given the various challenges a partner of a patient with a psychotic disorder must meet. Some of the difficulties may include coping with severely disturbed behavior during periods of acute psychotic episodes, disrupted household routines (e.g., as the result irregular sleeping and eating patterns and self-care), inappropriate interpersonal behavior, social withdrawal and emotional unresponsiveness. [23] In the present study, patients with schizophrenia showed a trend to better marital adjustment as compared with patients with bipolar affective disorder. This could due to the clinical features of both the disorders. Patients with bipolar affective disorder manifest with hyperactivity, increased energy, abusive and assaultive behavior during the manic phase. As the manic phase is perceived as a willful, spiteful act, the attitude of the spouses undergoes a marked change with feeling of betrayal and experiencing diminished self-esteem. Related to these issues of the spouse is the problem of marital infidelity. Often manic patients make sexual advances to other, may engage in affairs and speak of divorce. In all these situations, the spouse felt trapped in what they perceived as an impossible situation. They feel caught in a whirlwind of activity, personally threatened and powerless to enforce their will. In consonance with the above is the findings of a study that marital disharmony was greater when patients with bipolar disorder were ill and worse during manic than depressed phases. Marital disharmony was also more likely when partners believed the patient could control their illness, they had increased domestic responsibilities or were sexually dissatisfied. [24] On the other hand patients with schizophrenia most of the time present with negative symptoms and abnormal behavior, but violence is less common. Negative symptoms and loss of personal functioning are important factors in high expressed emotion in families with schizophrenia patients, being one of the reasons precisely the fact that they have many difficulties in acknowledge them as aspects of the illness and not personal will. However, it is possible that in our setting due to less violent behavior, this change in behavior may be viewed by the spouses as an illness over, which he has little control. As a result the spouses offer significant physical care and emotional support. In agreement with the above, it was reported that marital satisfaction of schizophrenics was influenced by violence from spouse. [25] The domain wise distribution shows significant difference on sexual adjustment domain and social adjustment domain between patients with substance dependence and bipolar affective disorder. It indicates bipolar affective disorder patients have poor sexual and social adjustment than patients with substance dependence. These findings are similar to findings of a previous study. [24] Similarly, there is significant difference found on sexual adjustment domain between substance dependence and schizophrenia patients. It indicates schizophrenia patients have poor sexual adjustment compared with patients with substance dependence. Inspection of the answers on MAQ showed some interesting trends. It appeared that the patients with bipolar affective disorder have overall poor marital adjustment and poor social adjustment domain due to lack of fulfillment in marital roles and responsibilities, poor economic adjustment, poor communication and poor problem solving. Emotional adjustment domain, analyzed on the basis of sharing of things and emotions, satisfaction about emotional needs, spending time with each other, likes and dislikes, in which the patients with schizophrenia found trend to better emotional adjustment domain than patients with bipolar affective disorder and patients with substance dependence. The substance dependence patients engaged in frequent and intense arguments have noticeable deficits in problem solving and communication skills, high rates of verbal and non-verbal negative affect expression, few supportive and constructive responses and show withdrawal during conflict. This could be the reason for the lack of emotional adjustment among substance dependence patients. Limitations No symptoms or personal functioning assessment was performed and cross-checked with the spouse for consistency. This would have given a better characterization of the sample considering that aspects such as marital adjustment demand a "fine tuning" in terms of personal and inter-personal evaluation.
There is significant difference on overall marital adjustment among substance dependence and bipolar affective disorder patients. Schizophrenia patients have significantly poor sexual adjustment than substance dependence patients. Patients with bipolar affective disorder have significantly poor sexual and social marital adjustment than patients with substance dependence. Schizophrenia and bipolar affective disorders patients do not significantly differ from each other on marital adjustment. Since majority of the patients with schizophrenia and bipolar affective disorder and 50% patients with substance dependence have poor marital adjustment, marital counseling should form a part of the psychosocial management of these patients.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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