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Abstract

Background:

Dissociative disorders invade and interfere with the person’s continuity of normal psychological functioning and exhibit slower or impaired processing of threat-related information and attachment styles play a significant role in their psychopathology. The present study assessed the type of attachment style and information processing biases and their relationship in adolescents with dissociative disorders.

Methods:

This was a hospital-based study, with a cross-sectional design based on purposive sampling. The study consisted of 50 participants between 11 and 17 years of age. Twenty-five of them were adolescents diagnosed with dissociative disorders and 25 were healthy adolescent controls. The Adolescent Dissociative Experiences Scale was used to assess the severity of dissociative disorders in adolescents. Emotional Stroop, Emotion Face dot-probe task and attachment style questionnaires were administered.

Results:

Findings suggested an association between the scores in the attachment style dimension of discomfort with closeness and information-processing biases in both the dot-probe and emotional Stroop tasks. There was also an association between the processing bias in the dot-probe task and relationships as a secondary attachment dimension. There was a difference in the two groups of adolescents with dissociative disorders and matched healthy adolescents with respect to the discomfort with closeness attachment style and information-processing bias scores of the dot-probe task.

Conclusion:

The study provides interesting insights into how information-processing biases correlate to attachment styles in adolescents with dissociative disorders. Results indicate extensive resources for future management.

Keywords

Adolescents attachment dissociation information-processing

Key Message:

There is a significant link between information processing biases and attachment styles among adolescents with dissociative disorders.

This study highlights correlations between information processing bias task scores and the domains of closeness and relationships as secondary attachment styles.

Therapeutic approaches focusing on the same are crucial for effectively addressing pathological dissociation in adolescents.

Adolescence is a critical stage of development characterized by profound psychological, emotional and social changes. It is a time when individuals begin to establish and navigate their identities, forming important relationships with peers, family and the broader society. However, for some adolescents, this developmental journey is marred by the presence of dissociative disorders, which introduce complex challenges to their ability to engage with the world and establish secure attachments. Dissociative disorders are common among children and adolescents, with the prevalence rate in India ranging from 12% to 31%.¹ It can impact the way they process information and their patterns of behaviour in and around relationships. They may experience difficulties in academics and everyday life activities increasing their susceptibility to developing additional mental conditions such as anxiety and depression.²

Dissociation is understood as characterized by ‘disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behaviour’.³ Essentially, the components of psychobiological functioning that should be connected are not. In more acute pathological dissociative presentations, the dissociation is primarily related to traumatic or overwhelming experiences.⁴ The origins and mechanisms of these disorders remain the subject of a lot of research,⁵ but it is increasingly recognized that a comprehensive understanding of their aetiology requires an exploration of not only their clinical symptoms but also their underlying cognitive and emotional processes.⁶

A significant factor in the development of adolescents that might be influenced by dissociative disorders is the formation of attachment styles.⁷ Attachment theory, pioneered by John Bowlby and later elaborated upon by Mary Ainsworth, emphasizes the importance of early relationships, particularly the child’s bond with primary caregivers, in shaping emotional regulation, interpersonal behaviours and overall well-being.⁸ Attachment styles, such as secure, anxious and avoidant, are associated with various aspects of psychological health and social functioning. Different studies^{9, 10} have shown how the disorganization of individual attachment during the early years of life predisposes one to respond with pathological dissociation to later traumas and life stressors and is correlated inversely with secure attachment, and positively with fearful and preoccupied attachment.⁹

Furthermore, the information processing biases inherent in individuals with dissociative disorders, such as attentional biases, memory distortions and altered perception of threat, can potentially interact with attachment dynamics.¹¹ These biases may influence how adolescents with dissociative disorders perceive and respond to their social environment, including the formation and maintenance of attachment bonds. An information-processing bias is pronounced when an individual demonstrates a distinctive manner of processing information within each cognitive domain such as memory and interpretation. People experiencing dissociative disorders often show a tendency to prematurely suppress the processing of conceptual information associated with emotional stimuli.¹² This incomplete processing is likely to result in heightened biases, indicating efforts to avoid such stimuli.¹³ Several researchers^{12, 14} have emphasized the importance of exploring information-processing characteristics that accompany heightened levels of dissociation. While research has explored these factors independently, there is a notable gap in understanding how they interrelate within the context of adolescent dissociative disorders.

Studies have also been done to examine the association between attachment styles and psychopathological symptoms in adolescents¹⁵ and generally showed that insecurely attached adolescents reported higher levels of dissociation. However, there has been no study to compare the role of attachment styles and the underlying link with the processing of information and the different biases leading to dissociation, especially in adolescents and in India. Thus, the findings from this study can help develop better and more holistic multi-faceted treatment and targeted intervention approaches for adolescents experiencing symptoms of dissociation and provide crucial support and resources to aid in their recovery and overall well-being.

This study aimed to investigate attachment styles and information-processing biases in adolescents with dissociative disorders and the relationship between them and compare them with duly matched controls.

Material and Methods

Design

The study conducted was a cross-sectional, comparative and hospital-based study. The potential participants of the study were recruited for the study using the purposive sampling technique. The study was conducted in a tertiary psychiatric hospital setting. The students for the control group were taken with the permission of the school authorities.

Participants

The sample size consisted of 50 adolescents within the age range of 11–17 years out of which 25 were adolescents diagnosed with dissociation according to the International Classification of Diseases (ICD-10), and Diagnostic Criteria for Research (DCR) criteria and 25 matched adolescent controls. Matching was done based on age, sex and education. Participants with comorbid psychiatric/organic disorders were excluded from the study.

Measures

The data was collected using standardized measures and tasks. The sociodemographic and clinical information data sheet was used to record the adolescents’ various socio-demographic and clinical variables.

The Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) was used to assess the 30 most prevalent and clinically significant disorders or subtypes in paediatric mental health while screening for any comorbid psychiatric diagnosis. This structured diagnostic interview aligns with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and ICD-10 psychiatric disorders in children and adolescents.¹⁶

To assess the overall level of functioning and impairment in adolescents due to dissociation, the Childhood Global Assessment Scale (CGAS) tool was used. This tool uses different scales to evaluate a child’s social, psychological and occupational functioning.¹⁷ Using a number scale ranging from 1 to 100, the CGAS assesses daily functioning and behaviours including personal hygiene habits, sleep patterns and risk of suicide. A lower CGAS score indicates more severe impairment in daily functioning.

Standard Progressive Matrices (SPM) were used to nonverbally assess intelligence in adolescents through abstract reasoning tasks. It comprises 60 problems organized into five sets of 12. Each problem involves completing a pattern or figure with a missing part and the task is to select the correct missing piece from six alternatives.¹⁸ The patterns are systematically arranged based on increasing levels of difficulty. The split-half method produces estimates that vary between 0.60 and 0.98, with a median value of 0.90. Raven provided test-retest coefficients for several age groups: 0.88 (13 years plus), 0.93 (under 30 years), 0.88 (30–39 years), 0.87 (40–49 years), 0.83 (50 years and over). It was used as a screening tool to exclude participants with below-average intelligence.

The Adolescent Dissociative Experience Scale (ADES) self-report instrument was utilized to gauge the frequency of dissociative experiences through 30 statements. Adolescents rated the occurrence of each experience on a scale of 0–10.¹⁹ The ADES score was determined by summing item scores and dividing by 30, resulting in a total score out of 10. Higher scores indicated increased levels of dissociation. The scale’s reliability and validity were assessed in a sample of adolescents aged 12–17 years,²⁰ revealing good internal consistency (Cronbach alpha = 0.90) and a two-week test-retest reliability (r = 0.77).

The Attachment Style Questionnaire was employed to explore attachment theory themes such as dependence, trust and self-reliance in relationships. With 40 items and responses ranging from One (totally disagree) to six (totally agree), factor analysis identified five scales: Confidence (C), discomfort with closeness (D), relationships as secondary (RS), need for approval (NA) and preoccupation with relationships (PR).²¹ Reliability coefficients were 0.74 (confidence and discomfort with closeness), 0.78 (need for approval), 0.72 (preoccupation with relationships) and 0.67 (relationships as secondary). The scale demonstrated validity through correlations with previous attachment measures and consistent patterns with measures of family functioning and personality.

Attentional biases for threatening faces were assessed using visual probe tasks, similar to those used in other anxiety-related disorders.²² In the dot-probe task, two stimuli with emotional value were presented simultaneously, followed by a neutral task involving probe detection. Reaction times were indicative of attentional interference by emotional expressions.

The emotional Stroop task featured emotional and neutral words displayed in different colours on a computer screen.²³ Adolescents identified colours while ignoring word meanings. The task showed high test-retest reliabilities for colour naming times but low reliabilities for interference scores (threat-related minus neutral response latencies).²⁴ An emotional interference score was calculated to measure the magnitude of the emotional Stroop effect.

Statistical Analysis

The data were analysed utilizing the Statistical Package for Social Sciences. Descriptive statistics were employed to depict the sample population concerning categorical socio-demographic and clinical variables. The Shapiro–Wilk test confirmed the normal distribution of the data. Given the homogeneity of both groups in terms of continuous variables such as age and educational qualification, an independent samples t-test was conducted for further comparative analysis. Pearson’s product-moment correlation was utilized to examine the relationships between various variables within the group of adolescents with dissociative disorders and the healthy control group of adolescents. The significance level (α) was set at both 0.01 and 0.05 levels.

Results

This study consisted of two groups: The clinical group comprised 25 adolescents (64% girls and 36% boys) fitting the inclusion and exclusion criteria diagnosed with dissociation according to ICD-10, DCR criteria and 25 healthy matched adolescent controls (again 64% girls and 36% boys). The age range was between 11 and 17 years, with a mean age of 15.2 years (SD = 1.6 years) and the two groups were matched in terms of age. The education in terms of years was between 10 and 15 years of education with a mean education being 12.7 years (SD = 1.6 years). The education was also matched between the two groups. Table 1 shows the sample characteristics of the clinical group. About 48% of adolescents in the clinical group were from a rural background and about 52% were from an urban background. Most of the adolescents were from a nuclear family (76%) and very few were from a joint family (24%). The sample in the clinical group was mostly Hindus (84%) and some Muslims (16%). With respect to the type of diagnosis, in the clinical group of adolescents with dissociative disorders, there were 17 adolescents (68% of the number of adolescents in the clinical group) with a diagnosis of mixed dissociative disorders (F44.7), five adolescents (20% of the number of adolescents in the clinical group) with a diagnosis of dissociative convulsions (F44.5), one adolescent (4% of the number of adolescents in the clinical group) with a diagnosis of dissociative stupor (F44.2) and two adolescents (8% of the number of adolescents in the clinical group) with a diagnosis of trance and possession disorders (F44.3).

Table 1.

Sample Characteristics in the Clinical Group.

Characteristics	N (%)
Sex Boys Girls	9 (36)16 (64)
Age (years), mean (SD)	15.2 (1.6)
Education (years), mean (SD)	12.7 (1.6)
Domicile Rural Urban	12 (48)13 (52)
Family type Joint Nuclear	6 (24)19 (76)
Religion Hindu Muslim	21 (84)4 (16)
Type of dissociation(according to ICD 10) Mixed dissociative disorders (F44.7) Dissociative convulsions (F44.5) Dissociative stupor (F44.2) Trance and possession disorders (F44.3)	17 (68)5 (20)1 (4)2 (8)

Table 2 displays descriptive statistics for all clinical variables in the clinical group. The mean age of onset of dissociation was 14.1 years (SD = 1.3). The duration of the illness had a mean of 1.4 years (SD = 0.9). The SPM Score had a mean of 48.1 (SD = 3.2). The CGAS score had a mean of 54.4 (SD = 0.3) indicating noticeable problems in the global functioning of adolescents in the clinical group. The ADES Score had a mean of 7.6 (SD = 2.1) suggesting pathological levels of dissociation in adolescents in the clinical group.

Table 2.

Scores in the Clinical Variables for the Clinical Group of Adolescents.

Clinical Variables	Mean	SD
Age of onset (years)	14.1	1.3
Duration of illness (years)	1.4	0.9
SPM score	48.1	3.2
CGAS score	54.4	0.3
ADES score	7.6	2.1

Correlations of attachment styles and information processing biases in the clinical group of adolescents with dissociative disorders.

Table 3 illustrates Pearson’s product-moment correlation coefficients depicting the associations between attachment styles and information-processing biases in a cohort of adolescents diagnosed with dissociative disorders. A significant positive correlation (r = 0.65) was identified between the discomfort attachment style and relationships as secondary attachment style at the 0.01 significance level. Furthermore, a significant and positive correlation was observed between the discomfort in relationships attachment style and information processing biases, both in the dot-probe task (r = 0.67) and the emotional Stroop task (r = 0.52) at the 0.01 significance level. There was also a significant moderate correlation (r = 0.43) between relationships as secondary attachment style and the information processing bias as measured in the dot-probe task. The scores obtained in the two tasks measuring information processing biases were also very strong positively and significantly correlated (r = 0.89) indicating that the two tasks measured the same variable.

Table 3.

Pearson’s Correlation Coefficients Between the Attachment Styles and Information Processing Biases in the Group of Adolescents with Dissociative Disorders.

Variables	Confidence	Discomfort	R as S	NA	P	Bias in DPT
Discomfort	–0.44
R as S	–0.42	0.65**
NA	0.30	–0.13	–0.064
P	0.17	–0.31	–0.296	0.25
Bias in DPT	0.12	0.67**	0.43**	0.27	–0.10
Bias in ST	0.26	0.52**	0.23	0.32	–0.13	0.89**

**Significant at the 0.01 level (2-tailed).

*Significant at the 0.05 level (2-tailed).

Notes: The values in the table indicate the Pearson correlation coefficient of the variables. Confidence: Confidence in relationships attachment style. Discomfort: Discomfort with closeness attachment style. R as S: Relationships as secondary attachment style. NA: Need for approval attachment style. P: Preoccupation with relationships attachment style. DPT: Dot-probe task. ST: Emotional Stroop task. Comparison between attachment styles and information processing biases in the clinical group of adolescents with dissociative disorders and the healthy control group of adolescents.

Table 4 shows the differences between the group of adolescents with dissociative disorders and the healthy control group of adolescents with respect to their attachment styles and information-processing biases using independent samples t-test. With respect to confidence in attachment style for both the groups, (mean and standard deviation for adolescents with dissociative disorders group = 21.10 ± 9.84, mean and standard deviation for healthy control group = 28.05 ± 9.59), the t-value was computed. The significance value of p = .76 indicated that the groups do not differ significantly with respect to confidence.

Table 4.

Independent Samples t-test of the Attachment Styles and Information Processing Biases Between Adolescents with Dissociative Disorders and Matched Healthy Adolescents.

Variables	Clinical Group	Healthy Control Group	t	df	p
Variables	Mean (SD)	Mean (SD)	t	df	p
Confidence	21.10 (9.84)	28.05 (9.59)	–0.31	48	.76
Discomfort	25.15 (11.07)	23.00 (9.51)	0.66	48	.04*
R as S	22.60 (8.27)	21.65 (7.83)	0.37	48	.71
NA	28.00 (10.74)	29.65 (7.93)	–0.55	48	.58
Preoccupation	28.85 (9.21)	25.80 (10.46)	0.98	48	.33
Bias in DPT	636.14 (25.78)	475.28 (18.70)	1.34	48	.03*
Bias in ST	540.66 (21.02)	445.48 (16.61)	1.61	48	.12

**Significant at the 0.01 level (2-tailed).

*Significant at the 0.05 level (2-tailed).

df: Degrees of freedom; Confidence: Confidence in relationships attachment style; Discomfort: Discomfort with closeness attachment style; R as S: Relationships as secondary attachment style; NA: Need for approval attachment style; Preoccupation: Preoccupation with relationships attachment style; DPT: Dot-probe task; ST: Emotional Stroop task.

With respect to the discomfort in relationship attachment style for both the groups, (mean and standard deviation for adolescents with dissociative disorders group = 25.15 ± 11.07, mean and standard deviation for healthy control group = 23.00 ± 9.51), the t-value was computed. The significance value of p = .04 indicated that the groups differed from each other with respect to discomfort in relationship attachment style (t = 0.66).

With respect to relationships as secondary attachment style for both the groups, (mean and standard deviation for adolescents with dissociative disorders group = 22.60 ± 8.27), mean and standard deviation for healthy control group = 21.65 ± 7.83), the t-value was computed. The significance value of p = .71 at 0.05 level, indicated that the groups do not differ significantly with respect to relationships as secondary attachment style.

With respect to the need for approval attachment style for both the groups, (mean and standard deviation for adolescents with dissociative disorders group = 28.00 ± 10.74, mean and standard deviation for healthy control group = 29.65 ± 7.93), the t-value was computed. The significance value of p = .58 at 0.05 level, indicated that the groups do not differ significantly with respect to the need for approval attachment style.

With respect to Preoccupation in Relationships attachment style for both the groups, (mean and standard deviation for adolescents with dissociative disorders group = 28.85 ± 9.21, mean and standard deviation for healthy control group = 25.80 ± 10.46), the t-value was computed. The significance value of p = .33 at 0.05 level, indicated that the groups do not differ significantly with respect to preoccupation in relationships attachment style.

With respect to information processing bias as measured by the dot-probe task, (mean and standard deviation for adolescents with dissociative disorders group = 636.14 ± 25.78, mean and standard deviation for healthy control group = 475.28 ± 18.70), the t-value was computed. The significance value of p = .03, indicated that the groups did differ with respect to the information processing bias measured by the dot-probe task (t = 1.34).

With respect to Information processing bias as measured by the emotional Stroop task, (mean and standard deviation for adolescents with dissociative disorders group = 540.66 ± 21.02, mean and standard deviation for healthy control group = 445.48 ± 16.61), the t-value was computed. The significance value of p = .12 indicated that the groups did not differ significantly with respect to the information processing bias as measured by the emotional Stroop task.

Discussion

To our knowledge, this is the first study to assess the relationship between biases in information processing and attachment style in adolescents with dissociative disorders, especially in India. The interaction between the two variables and how they impact dissociative symptoms would help holistically understand the different dissociative disorders, especially in adolescents. The two groups were compared to help understand whether these associations are also seen in a group of healthy adolescents and how assessing them can open venues for intervention in the same.

There was a female preponderance in adolescents with dissociative disorders (64% of the total clinical group of adolescents). This has also been seen in several other prevalence studies conducted in the Indian setting where the occurrence of dissociative disorders in females is higher than in males.²⁵

Mixed dissociative disorders (68%) had the highest presentation in the group of adolescents in this study, followed by dissociative convulsions (20%). Previous prevalence studies in India also showed that motor symptoms have the most common presentation in the Indian setting.²⁶

For adolescents with dissociative disorders, the scores obtained in the two subscales discomfort with closeness and relationships as secondary were correlated. Discomfort with closeness is a theme central to Hazan and Shaver’s conceptualization of avoidant attachment.²⁶ In contrast, the dimension relationships as secondary dimension is consistent with Bartholomew’s²⁷ concept of dismissive attachment²⁸ indicating both of them being similar concepts that are correlated to each other.

The scores obtained in both the emotional Stroop task and dot-probe task were correlated to each other for the clinical group of adolescents with dissociative disorders. Both tasks are used to assess the processing of information of threat-related stimuli. These interference effects in the emotional Stroop task are usually interpreted as information processing biases towards threat-related information. In the trials of the dot-probe task, reaction times to the dot are used as a measure for bias in processing threats. Quick reactions to dots that appeared in the positions of threat words and slowly responding dots that appeared in the positions of neutral words suggest a threat-focused bias in processing information.²⁹ The scores in the two tasks were also correlated to the discomfort in closeness attachment style. This showed that attachment avoidance was also associated with the avoidance of threat-related stimuli showing a bias in processing threat-related information as measured by the two tasks. There was also a correlation between the scores obtained on the relationships as secondary dimension and the dot-probe task. Similarly, this is indicative that adolescents who had a dismissive style of attachment also showed a tendency towards avoidance of processing emotional information. Previous studies³⁰ have also shown how high levels of attachment avoidance incline people to avoid processing attachment-related threatening information (which may be the emotional faces in the present study). Zimmermann and Iwanski³¹ stated how those with insecure internal working attachment models can receive stimuli in one of two ways: either they exclude information out of fear that it will cause them psychological distress or cause them to feel harmed, or they process emotional information in a negatively biased manner.

Comparing the two groups of adolescents, there was a significant difference in the domain of discomfort with closeness attachment style. This is consistent with previous studies as well which have shown a relationship between attachment and dissociation³² and even adolescent samples confirm this association.³³ In a study by Nilsson et al.,³⁴ they assessed self-reported attachment styles in adolescents and found the insecure attachment style scores to be strongly correlated to dissociative symptoms. When adolescents experience discomfort in closeness in attachment with others they may have a reduced capacity to regulate negative emotional states increasing the likelihood that when they are confronted with potentially traumatic experiences and the attachment system is activated, they are more likely to develop dissociative symptomatology due to fragmented and multiple experiences of self and others.

There was also a significant difference in scores of the emotional dot-probe task indicating that there is a difference in the biases of information processing in adolescents with dissociative disorders. Studies have shown that the cognitive characteristics of individuals with higher levels of dissociation are usually slower processing of threat-related information or emotional information.³⁵ There may be a tendency to block out threatening information reflected in interference with other tasks (detection of the position of the dot) wherein the relevant emotional material (emotional faces) activates relatively complex schemata that conflict with the neutral task. Due to the cognitive processing required for such schemata, there are fewer resources available for the overt task, which is dot detection, which slows performance and introduces bias.

Limitations

We tried to maintain the qualities of a good scientific study, but some of the limitations could not be avoided. First, sample size estimation was not calculated based on the population to claim the proper representation. Second, the emotional and neutral faces used in the emotion dot-probe task were not Indian faces and hence may not have been well validated in this culture. Further, the sample was collected only from one hospital set-up and one school; therefore, only a particular stratum could be included. We used a purposive sampling method that might have increased the error variance. Since data was collected based on the subjective rating of the participants, the findings could have been influenced by the motivational and other emotional factors in the participants’ way of responding. And finally, the cross-sectional design of the study does not allow the establishment of a cause-effect relationship or the examination of the participants’ behaviour over a period.

Implications

Considering the current scenario of the emerging cases and the distress that children and adolescents and their family members report and the lack of awareness in India, this study highlights some important findings that can help in the understanding of dissociative disorder and planning for intervention. A more comprehensive approach needs to be adopted to help understand other factors, which interact to cause dissociative symptoms in adolescents. The role of parenting concerning attachment styles needs to be assessed and understood to gain a holistic understanding and develop family intervention modules. Further research work on the interaction of attachment patterns and information processing biases across other psychiatric disorders can also be done to make the associations clearer. Development of faces in the dot-probe task valid for this culture is important to better connect with the adolescents here, especially for the ones from a rural background or the lower socio-economic strata. A longitudinal approach can help to understand the attachment styles and their influences when the dissociative symptoms subside. Based on the main highlights from this study, a holistic approach to the treatment regime should be adopted, thereby planning different intervention approaches like cognitive-behavioural psychotherapy, mindfulness-based cognitive therapy for children, interpersonal therapy, problem-solving skills training, coping skill enhancement, components of dialectical behaviour therapy and other aspects that can help adolescents increase social-emotional resiliency through the enhancement of mindful attention and targets difficulties in the attachment which further impact current interpersonal relationships.

Conclusion

The current research offers valuable insights into the association between information-processing biases and attachment styles in adolescents diagnosed with dissociative disorders. The scores obtained in the information-processing bias task exhibited correlations with the domains of discomfort with closeness and relationships as secondary attachment styles. Consequently, therapeuticapproaches that address information processing biases and draw from attachment theory, such as cognitive-behavioural therapies, mindfulness-based therapies, interpersonal therapy or attachment therapy, may be pertinent for adolescents experiencing pathological dissociation.

Footnotes

The authors express their gratitude to the participants for their participation in the study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,authorship and/or publication of this article.

Declaration Regarding the Use of Generative AI

None used.

Ethical Approval and Patient Consent

Ethical approval was taken from the Institute's Ethics Committee. The school authorities granted permission. The participants provided informed assent,and parents provided written consent.

Funding

The authors received no financial support for the research,authorship,and/or publication of this article.

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