Background Alopecia areata (AA) is a common and chronic skin disease with an unknown etiology. It may significantly affect the patient quality of life. This study was designed to evaluate the illness perception in patients with AA.
Background
Alopecia areata (AA) is a common and chronic skin disease with an unknown etiology. It may significantly affect the patient quality of life. This study was designed to evaluate the illness perception in patients with AA.Methods A questionnaire consisting of 25 questions about causes, timeline, consequences and control of disease were given to 80 patients with AA attending a skin clinic in Tehran, Iran. The impact of age, gender, duration of disease, education, extent of disease and family history of AA were also assessed.
Methods
A questionnaire consisting of 25 questions about causes, timeline, consequences and control of disease were given to 80 patients with AA attending a skin clinic in Tehran, Iran. The impact of age, gender, duration of disease, education, extent of disease and family history of AA were also assessed.Results Eighty patients (38 male and 42 female) with a mean age of 27.5 years (SD = 9.3) and disease duration of 7.8 years (SD = 7.7) completed the questionnaire. 76.9% of the patients believed that the role of stress was the cause of disease. 17.1 % believed genetic background to be the main cause, this found to be more frequent in patients with positive family history of AA. More than half of patients believed that their illness had major consequences on their lives and 40% of patients believed that their illness would be likely to be permanent rather than temporary, more in patients with longer duration of disease. Only 57.5% of patients considered their treatments to be effective.
Results
Eighty patients (38 male and 42 female) with a mean age of 27.5 years (SD = 9.3) and disease duration of 7.8 years (SD = 7.7) completed the questionnaire. 76.9% of the patients believed that the role of stress was the cause of disease. 17.1 % believed genetic background to be the main cause, this found to be more frequent in patients with positive family history of AA. More than half of patients believed that their illness had major consequences on their lives and 40% of patients believed that their illness would be likely to be permanent rather than temporary, more in patients with longer duration of disease. Only 57.5% of patients considered their treatments to be effective.Conclusion AA may considerably affect various aspects of patients' lives. The patient knowledge about the causes and course of this disease is limited.
Conclusion
AA may considerably affect various aspects of patients' lives. The patient knowledge about the causes and course of this disease is limited.

Background Alopecia areata (AA) is manifested as a sudden loss of hairs without any inflammation or scarring. The hair loss might be seen in a circumscribed area or the whole scalp (alopecia totalis or AT) or whole body (alopecia universalis or AU) [ 1 ]. It is a common disease and at any given time, 0.2% of the population has AA and 1.7% of the population will experience an episode of AA during their lifetime [ 2 , 3 ]. The etiology of AA is not known exactly. However factors such as genetic predisposition, autoimmunity, and stress have been suggested [ 4 , 5 ]. The course of disease is not predictable and it is often associated with periods of hair loss and regrowth. The clinical severity of a patient's AA may not be a good indicator of subsequent downturn in quality of life or psychological well-being. The onset of a chronic condition brings with it a range of difficulties that may show considerable variation in their nature and severity as perceived by the patient. In order to make sense of and respond to the difficulties that chronic illness may present, patients construct their own common-sense cognitive model of their condition. Such models are based upon information received from a range of sources including their physician, family, friends, and existing social and cultural notions about health and illness. The resulting system of beliefs can of course be flawed or inaccurate; however there is evidence that it is those beliefs that drive attempts to cope with a condition and issues of compliance with treatment. Patient-held beliefs have important implications for the clinical management of their disease. Studies on patients with psoriasis and acne vulgaris have shown that knowledge of patients about their condition, the course of their disease and current treatments is not appropriate [ 6 , 7 ]. In this study, we examined the system of beliefs held by AA patients and the factors that might influence such beliefs.
Background
Alopecia areata (AA) is manifested as a sudden loss of hairs without any inflammation or scarring. The hair loss might be seen in a circumscribed area or the whole scalp (alopecia totalis or AT) or whole body (alopecia universalis or AU) [ 1 ]. It is a common disease and at any given time, 0.2% of the population has AA and 1.7% of the population will experience an episode of AA during their lifetime [ 2 , 3 ]. The etiology of AA is not known exactly. However factors such as genetic predisposition, autoimmunity, and stress have been suggested [ 4 , 5 ]. The course of disease is not predictable and it is often associated with periods of hair loss and regrowth. The clinical severity of a patient's AA may not be a good indicator of subsequent downturn in quality of life or psychological well-being.The onset of a chronic condition brings with it a range of difficulties that may show considerable variation in their nature and severity as perceived by the patient. In order to make sense of and respond to the difficulties that chronic illness may present, patients construct their own common-sense cognitive model of their condition. Such models are based upon information received from a range of sources including their physician, family, friends, and existing social and cultural notions about health and illness. The resulting system of beliefs can of course be flawed or inaccurate; however there is evidence that it is those beliefs that drive attempts to cope with a condition and issues of compliance with treatment. Patient-held beliefs have important implications for the clinical management of their disease. Studies on patients with psoriasis and acne vulgaris have shown that knowledge of patients about their condition, the course of their disease and current treatments is not appropriate [ 6 , 7 ].In this study, we examined the system of beliefs held by AA patients and the factors that might influence such beliefs.Methods The Illness Perception Questionnaire (IPQ) [ 8 ] with a few modifications was given to 80 patients with AA older than 12 years, attending a private skin clinic in Tehran, Iran in 1999. The study was approved by Institutional Review Board of the Center for Research and Training in Skin Diseases and Leprosy. The IPQ was created to provide a theoretically derived measurement instrument suitable for use with any patient population. It has been used in patients with cardiac disease [ 9 ], chronic fatigue syndrome [ 10 ], diabetes, chronic pain, rheumatoid arthritis [ 8 ], and psoriasis [ 6 ]. As AA is an asymptomatic disease, we did not use the subscale of "symptoms" in our study. Thus the questionnaire that we used consisted of four subscales: Cause  subscale (10 items) measures personal ideas about the cause of AA. Time line  (3 items) deals with perceptions about how long the disease will last. Consequences  (6 items) are concerned with expected effects and outcomes of the illness. Cure/Control  (6 items) details beliefs about recovery from or control of the condition. There were four possible answers for each item in the IPQ to be chosen by patients: I strongly agree, I agree, I do not know, I disagree. Furthermore, some demographic information such as age, sex, family history of AA, and duration and extent of disease (alopecia areata or AT/AU), and level of education were obtained from the patients to evaluate their influence on patients' beliefs. Statistical analysis was conducted by means of SPSS statistical software, version 11.0. Because the data were not normally distributed, nonparametric statistics were used. Correlations were processed by Spearman's rank correlation, and differences between means were computed by means of the Mann-Whitney U test. For simplicity of analysis and increasing the power of study, the answers of "I strongly agree" and "I agree" were grouped together and compared with the answers of "I don't know" and "I disagree" which were grouped together as "I do not agree". A p value of less than 0.05 was considered as significant.
Methods
The Illness Perception Questionnaire (IPQ) [ 8 ] with a few modifications was given to 80 patients with AA older than 12 years, attending a private skin clinic in Tehran, Iran in 1999. The study was approved by Institutional Review Board of the Center for Research and Training in Skin Diseases and Leprosy. The IPQ was created to provide a theoretically derived measurement instrument suitable for use with any patient population. It has been used in patients with cardiac disease [ 9 ], chronic fatigue syndrome [ 10 ], diabetes, chronic pain, rheumatoid arthritis [ 8 ], and psoriasis [ 6 ]. As AA is an asymptomatic disease, we did not use the subscale of "symptoms" in our study. Thus the questionnaire that we used consisted of four subscales:Cause  subscale (10 items) measures personal ideas about the cause of AA.CauseTime line  (3 items) deals with perceptions about how long the disease will last.Time lineConsequences  (6 items) are concerned with expected effects and outcomes of the illness.ConsequencesCure/Control  (6 items) details beliefs about recovery from or control of the condition.Cure/ControlThere were four possible answers for each item in the IPQ to be chosen by patients: I strongly agree, I agree, I do not know, I disagree.Furthermore, some demographic information such as age, sex, family history of AA, and duration and extent of disease (alopecia areata or AT/AU), and level of education were obtained from the patients to evaluate their influence on patients' beliefs.Statistical analysis was conducted by means of SPSS statistical software, version 11.0. Because the data were not normally distributed, nonparametric statistics were used. Correlations were processed by Spearman's rank correlation, and differences between means were computed by means of the Mann-Whitney U test. For simplicity of analysis and increasing the power of study, the answers of "I strongly agree" and "I agree" were grouped together and compared with the answers of "I don't know" and "I disagree" which were grouped together as "I do not agree". A p value of less than 0.05 was considered as significant.Results A total of 80 patients with AA (38 male, 42 female), with a mean age of 27.5 years (SD 9.3, ranged from 13 to 56 years) were recruited to the study. The mean duration of illness was 7.8 years (SD 7.7, ranged from 1 month to 30 years). In 75% of patients, AA was patchy and it was totalis or universalis in 25%. Fifteen percent of patients had a positive family history of AA in their first degree relatives. Physicians were the main source of patients' information about their disease in 66.2% of them. Beliefs about cause Table.  1  shows the percentage of patients "agreeing" with each  cause  item. A total of 76.9% of patients believed that stress was a major factor in onset of their illness and older patients were more likely to believe in this (p < 0.05). Patients who had a belief that their disease was a result of genetic factor were more likely to have a family history of AA and longer duration of the disease (P < 0.05). Younger patients and those with extensive disease (AT/AU) believed that their illness was because of chance or fate (P < 0.05). Table 1 Beliefs about causes of alopecia areata (n = 80) Causes Agree Factors influencing beliefs Stress 76.9% Older patients (p = 0.012) My state of mind 59.2% None My own behavior 47.3% None Other people 34.2% None Chance or fate 31.1% Younger patients(p = 0.021), extensive disease (AT/AU)(p = 0.030) Diet 25.7 % None Pollution 24.3% None Germ or virus 21.9% None Genetic 17.1% Family history of AA(p = 0.006), longer duration(p = 0.017) Poor medical care 11.8% None Beliefs about consequences Majority of the patients (58.2%) believed that their illness had a major consequence on their lives, 53.8% of patients also felt that AA had strongly affected their self-esteem, and 50.6% considered AA as a serious condition. These believes were stronger in younger patients, and in patients who had the disease for a long time (p < 0.05). Table  2  shows the percentage of patients "agreeing" with each  consequence  item. Table 2 Beliefs about consequences of having alopecia areata (n = 80) Beliefs Agree Factors influencing beliefs My disease has had a major consequence on my life. 58.2% Younger patients(p = 0.012), longer duration(p = 0.014) My disease has strongly affected the way I see myself as a person. 53.8% Younger age at onset(p = 0.003) My disease has strongly affected the way others see me. 51.3% Younger age at onset(p = 0.022), longer duration(p = 0.012) My disease is a serious condition. 50.6% Younger age at onset(p = 0.003), younger patients(p = 0.013) My disease has become easier to live with. 50.6% None My disease has serious economic and financial consequences. 27.8% Younger age at onset(p = 0.015), longer duration(p = 0.010) Beliefs about recurrence or chronicity Half of the patients believed whether their disease cleared, it would always come back and forty percent of patients believed that their illness would be likely to be permanent rather than temporary. They were more likely to have a longer duration of disease (p < 0.05). The minority of patients (25.0%) believed that their illness would last a short time. Beliefs about cure and control More than 60% of patients believed that their behavior could determine improvement or worsening of their illness (table  3 ). This belief was present in female patients more than male patients (p < 0.05). 30.4% of patients believed there was very little that could be done to improve their illness. They were more likely to have longer duration of disease (P < 0.05). Thirty-eight percent of the patients believed that recovery from disease is largely dependent on chance or fate. This belief was stronger in female patients, those with younger age at onset, and patients with extensive disease (p < 0.05). Table 3 Beliefs about cure and control (n = 80) Beliefs Agree Factors influencing beliefs What I do can determine whether my disease gets better or worse. 63.3% Female patients(p = 0.010) My treatment will be effective in curing my disease. 57.5% None My disease will improve in time. 53.2% Older patients(p = 0.006), older age at onset(p = 0.029) There is a lot that I can do to control my disease. 52.5% None Recovery from my disease is largely dependent on chance or fate. 38.0% Female patients(p = 0.014), younger age at onset(p = 0.036), extensive disease (AT/AU)(p = 0.021) There is very little that can be done to improve my disease. 30.4% Longer duration(p = 0.004)
Results
A total of 80 patients with AA (38 male, 42 female), with a mean age of 27.5 years (SD 9.3, ranged from 13 to 56 years) were recruited to the study. The mean duration of illness was 7.8 years (SD 7.7, ranged from 1 month to 30 years). In 75% of patients, AA was patchy and it was totalis or universalis in 25%. Fifteen percent of patients had a positive family history of AA in their first degree relatives. Physicians were the main source of patients' information about their disease in 66.2% of them.Beliefs about cause Table.  1  shows the percentage of patients "agreeing" with each  cause  item. A total of 76.9% of patients believed that stress was a major factor in onset of their illness and older patients were more likely to believe in this (p < 0.05). Patients who had a belief that their disease was a result of genetic factor were more likely to have a family history of AA and longer duration of the disease (P < 0.05). Younger patients and those with extensive disease (AT/AU) believed that their illness was because of chance or fate (P < 0.05). Table 1 Beliefs about causes of alopecia areata (n = 80) Causes Agree Factors influencing beliefs Stress 76.9% Older patients (p = 0.012) My state of mind 59.2% None My own behavior 47.3% None Other people 34.2% None Chance or fate 31.1% Younger patients(p = 0.021), extensive disease (AT/AU)(p = 0.030) Diet 25.7 % None Pollution 24.3% None Germ or virus 21.9% None Genetic 17.1% Family history of AA(p = 0.006), longer duration(p = 0.017) Poor medical care 11.8% None
Beliefs about cause
Table.  1  shows the percentage of patients "agreeing" with each  cause  item. A total of 76.9% of patients believed that stress was a major factor in onset of their illness and older patients were more likely to believe in this (p < 0.05). Patients who had a belief that their disease was a result of genetic factor were more likely to have a family history of AA and longer duration of the disease (P < 0.05). Younger patients and those with extensive disease (AT/AU) believed that their illness was because of chance or fate (P < 0.05).causeBeliefs about causes of alopecia areata (n = 80)CausesAgreeFactors influencing beliefsBeliefs about consequences Majority of the patients (58.2%) believed that their illness had a major consequence on their lives, 53.8% of patients also felt that AA had strongly affected their self-esteem, and 50.6% considered AA as a serious condition. These believes were stronger in younger patients, and in patients who had the disease for a long time (p < 0.05). Table  2  shows the percentage of patients "agreeing" with each  consequence  item. Table 2 Beliefs about consequences of having alopecia areata (n = 80) Beliefs Agree Factors influencing beliefs My disease has had a major consequence on my life. 58.2% Younger patients(p = 0.012), longer duration(p = 0.014) My disease has strongly affected the way I see myself as a person. 53.8% Younger age at onset(p = 0.003) My disease has strongly affected the way others see me. 51.3% Younger age at onset(p = 0.022), longer duration(p = 0.012) My disease is a serious condition. 50.6% Younger age at onset(p = 0.003), younger patients(p = 0.013) My disease has become easier to live with. 50.6% None My disease has serious economic and financial consequences. 27.8% Younger age at onset(p = 0.015), longer duration(p = 0.010)
Beliefs about consequences
Majority of the patients (58.2%) believed that their illness had a major consequence on their lives, 53.8% of patients also felt that AA had strongly affected their self-esteem, and 50.6% considered AA as a serious condition. These believes were stronger in younger patients, and in patients who had the disease for a long time (p < 0.05). Table  2  shows the percentage of patients "agreeing" with each  consequence  item.consequenceBeliefs about consequences of having alopecia areata (n = 80)BeliefsAgreeFactors influencing beliefsBeliefs about recurrence or chronicity Half of the patients believed whether their disease cleared, it would always come back and forty percent of patients believed that their illness would be likely to be permanent rather than temporary. They were more likely to have a longer duration of disease (p < 0.05). The minority of patients (25.0%) believed that their illness would last a short time.
Beliefs about recurrence or chronicity
Half of the patients believed whether their disease cleared, it would always come back and forty percent of patients believed that their illness would be likely to be permanent rather than temporary. They were more likely to have a longer duration of disease (p < 0.05). The minority of patients (25.0%) believed that their illness would last a short time.Beliefs about cure and control More than 60% of patients believed that their behavior could determine improvement or worsening of their illness (table  3 ). This belief was present in female patients more than male patients (p < 0.05). 30.4% of patients believed there was very little that could be done to improve their illness. They were more likely to have longer duration of disease (P < 0.05). Thirty-eight percent of the patients believed that recovery from disease is largely dependent on chance or fate. This belief was stronger in female patients, those with younger age at onset, and patients with extensive disease (p < 0.05). Table 3 Beliefs about cure and control (n = 80) Beliefs Agree Factors influencing beliefs What I do can determine whether my disease gets better or worse. 63.3% Female patients(p = 0.010) My treatment will be effective in curing my disease. 57.5% None My disease will improve in time. 53.2% Older patients(p = 0.006), older age at onset(p = 0.029) There is a lot that I can do to control my disease. 52.5% None Recovery from my disease is largely dependent on chance or fate. 38.0% Female patients(p = 0.014), younger age at onset(p = 0.036), extensive disease (AT/AU)(p = 0.021) There is very little that can be done to improve my disease. 30.4% Longer duration(p = 0.004)
Beliefs about cure and control
More than 60% of patients believed that their behavior could determine improvement or worsening of their illness (table  3 ). This belief was present in female patients more than male patients (p < 0.05). 30.4% of patients believed there was very little that could be done to improve their illness. They were more likely to have longer duration of disease (P < 0.05). Thirty-eight percent of the patients believed that recovery from disease is largely dependent on chance or fate. This belief was stronger in female patients, those with younger age at onset, and patients with extensive disease (p < 0.05).Beliefs about cure and control (n = 80)BeliefsAgreeFactors influencing beliefsDiscussion Alopecia areata is a chronic disease which may influence individual or social aspects of patients' lives. The results of our study confirmed this fact as the majority of patients believed that their illness had strongly affected their lives. It also influenced their self-esteem. The results of studies in other chronic diseases with periods of remission and exacerbation have had different results in this respect. For example in a study on acne patients, the disease had affected patients' self-image in nearly all of them, but it had no impact on interpersonal relationships, work, or school activities in majority of patients [ 7 ]. On the other hand, in a study on patients with psoriasis using the IPQ questionnaire, 68% of patients who suffered from psoriasis, agreed that psoriasis had a major consequence on their lives, and 53.4% agreed that psoriasis had strongly affected the way they saw themselves as a person [ 6 ]. The present study also investigated cognitive appraisals held by patients about their illness and showed that such beliefs were not associated in any significant manner with the extent of their condition. Fortune et al also did not find an association between the clinical severity of psoriasis and beliefs held by patients about their condition [ 6 ]. Thus the assumption that the objective severity of a condition will be associated in a linear fashion with patient's subjective experience in terms of beliefs, coping, or distress is unlikely to be correct. On the other hand, young patients and those with longer duration of disease were more likely to be affected by their disease. This implies that the chronicity of the disease has more influence on patient's life than the extent of it. The results of our study also showed that the beliefs about the consequences of having AA were not influenced by the gender of the patients. Thus men are as vulnerable as women in suffering from the consequences of AA. Patients with AA, including 77% of patients in this study, often attribute the onset of their disease to a specific stressful life event. In a study on 178 patients, Van der Steen  et al.  showed that emotional stress is not an important factor in the initiation of AA [ 11 ]. Brajac  et al.  did not find a significant role of stress in the onset of AA but stressful life events had an important role in triggering of some episodes of disease [ 12 ]. On the other hand, Gupta  et al.  found that AA patients who were depressed, were more likely to mention stress as the cause of their disease [ 13 ]. In recent studies, psychologic and psychopathologic factors have been analyzed as modulators of neuroendocrinologic, vascular, and immunologic variables; this is far from the initial concept of stress being the causal agent in the illness. In fact, stress may cause its effect by making alterations in immune responses related to neuropeptides, such as the migration of the macrophages, vasodilator or vasoconstrictor responses, phagocytosis, lymphocytic cellular immunity, and expression of some factors of leukocytic adhesion to the microvascular endothelium [ 14 ]. In addition, the adaptation to the illness is regarded as an important factor with regard to prognosis. However the exact cause of AA is not known and such events are very common, making it difficult for the investigator to prove that they are in fact involved in causing or precipitating the disease. In this study, one-third of the patients believed in chance or fate as the cause of AA, and this belief was stronger in younger patients and those with extensive disease (AT/AU). This study also showed that as AA lasts, the patients feel more hopeless about time line and treatment modalities of their disease. The majority of patients had no hope to get rid of their disease. Almost half of patients expected their disease to relapse after it disappeared. Such perpetual stresses are hardly endurable. The psychiatrists' intervention may alleviate patients' stress and improve their quality of life. This study was performed in a private dermatology clinic. The possibility of socioeconomic homogeneity among recruited patients may be biasing the results. So it should be considered that these results may be different in patients with AA in different socioeconomic and cultural backgrounds.
Discussion
Alopecia areata is a chronic disease which may influence individual or social aspects of patients' lives. The results of our study confirmed this fact as the majority of patients believed that their illness had strongly affected their lives. It also influenced their self-esteem. The results of studies in other chronic diseases with periods of remission and exacerbation have had different results in this respect. For example in a study on acne patients, the disease had affected patients' self-image in nearly all of them, but it had no impact on interpersonal relationships, work, or school activities in majority of patients [ 7 ]. On the other hand, in a study on patients with psoriasis using the IPQ questionnaire, 68% of patients who suffered from psoriasis, agreed that psoriasis had a major consequence on their lives, and 53.4% agreed that psoriasis had strongly affected the way they saw themselves as a person [ 6 ].The present study also investigated cognitive appraisals held by patients about their illness and showed that such beliefs were not associated in any significant manner with the extent of their condition. Fortune et al also did not find an association between the clinical severity of psoriasis and beliefs held by patients about their condition [ 6 ]. Thus the assumption that the objective severity of a condition will be associated in a linear fashion with patient's subjective experience in terms of beliefs, coping, or distress is unlikely to be correct. On the other hand, young patients and those with longer duration of disease were more likely to be affected by their disease. This implies that the chronicity of the disease has more influence on patient's life than the extent of it.The results of our study also showed that the beliefs about the consequences of having AA were not influenced by the gender of the patients. Thus men are as vulnerable as women in suffering from the consequences of AA.Patients with AA, including 77% of patients in this study, often attribute the onset of their disease to a specific stressful life event. In a study on 178 patients, Van der Steen  et al.  showed that emotional stress is not an important factor in the initiation of AA [ 11 ]. Brajac  et al.  did not find a significant role of stress in the onset of AA but stressful life events had an important role in triggering of some episodes of disease [ 12 ]. On the other hand, Gupta  et al.  found that AA patients who were depressed, were more likely to mention stress as the cause of their disease [ 13 ].et al.et al.et al.In recent studies, psychologic and psychopathologic factors have been analyzed as modulators of neuroendocrinologic, vascular, and immunologic variables; this is far from the initial concept of stress being the causal agent in the illness. In fact, stress may cause its effect by making alterations in immune responses related to neuropeptides, such as the migration of the macrophages, vasodilator or vasoconstrictor responses, phagocytosis, lymphocytic cellular immunity, and expression of some factors of leukocytic adhesion to the microvascular endothelium [ 14 ]. In addition, the adaptation to the illness is regarded as an important factor with regard to prognosis. However the exact cause of AA is not known and such events are very common, making it difficult for the investigator to prove that they are in fact involved in causing or precipitating the disease. In this study, one-third of the patients believed in chance or fate as the cause of AA, and this belief was stronger in younger patients and those with extensive disease (AT/AU).This study also showed that as AA lasts, the patients feel more hopeless about time line and treatment modalities of their disease. The majority of patients had no hope to get rid of their disease. Almost half of patients expected their disease to relapse after it disappeared. Such perpetual stresses are hardly endurable. The psychiatrists' intervention may alleviate patients' stress and improve their quality of life.This study was performed in a private dermatology clinic. The possibility of socioeconomic homogeneity among recruited patients may be biasing the results. So it should be considered that these results may be different in patients with AA in different socioeconomic and cultural backgrounds.Conclusion There is a need for accessible, accurate, community-based education on the natural history of AA, the effectiveness and expected duration of treatment. The inadequacy of information provided by current sources is evident in ongoing misconceptions on causality and the perceptions of respondents. Incorporating information on this disease may facilitate patient into therapeutic selection, enhance understanding of treatment options and improve patient compliance.
Conclusion
There is a need for accessible, accurate, community-based education on the natural history of AA, the effectiveness and expected duration of treatment. The inadequacy of information provided by current sources is evident in ongoing misconceptions on causality and the perceptions of respondents. Incorporating information on this disease may facilitate patient into therapeutic selection, enhance understanding of treatment options and improve patient compliance.Competing interests The author(s) declare that they have no competing interests.
Competing interests
The author(s) declare that they have no competing interests.Authors' contributions AF participated in the design and conduct of the study and preparation of the manuscript. MRF participated in the conduct of the study and statistical analysis. BG participated in the conduct of the study and statistical analysis. YD participated in the design of the study and preparation of the manuscript. All authors read and approved the final manuscript.
Authors' contributions
AF participated in the design and conduct of the study and preparation of the manuscript.MRF participated in the conduct of the study and statistical analysis.BG participated in the conduct of the study and statistical analysis.YD participated in the design of the study and preparation of the manuscript.All authors read and approved the final manuscript.Pre-publication history The pre-publication history for this paper can be accessed here:
Pre-publication history
The pre-publication history for this paper can be accessed here:


Imagination and creativity are essential traits that medicine, and medical insurers, must again learn to recognize and reward

Galvanized by rising costs, increased calls for greater, accountability, and an Institute of Medicine (Washington, D. C., United States) report suggesting that medical errors may kill nearly 100,000 Americans every year  [1] , United States health care experts have tried to boost the quality of patient care by focusing on the speed and precision of service delivery. Several insurance companies have already started to place a surcharge on patients who elect to receive care from “inefficient” providers (a definition that includes most teaching hospitals), hoping to encourage patients to seek more cost-effective service, and to encourage physicians to provide it  [2] .The problem is, most of these reform efforts, while critically important, only capture half the picture. Efficiency isn't everything, and unless we learn to cultivate creativity as avidly as we pursue consistency, future generations of patients may find themselves stuck with the same basic treatments they're receiving today. It will be the same medicine, just served quickly.Benefits of Quality Reform From its earliest days, medical training was based on an apprenticeship model, in which junior acolytes learned the art from senior practitioners. Even with the evolution of modern medical schools, which offered future physicians a rigorous common training, once doctors entered the real world they essentially did as they pleased. Consequently, there were pronounced differences in approaches to common problems from one clinician to another. There was also little to guarantee that once doctors had hung out their shingle, they were actually competent (and remained competent) to practice their craft. While most physicians remained committed to the general professional standard—do the best that you can for each individual patient— many well-meaning doctors ultimately were not delivering their patients the best care available. More recently, and largely due to the contagious spread of the so-called “business model,” there has been an increased emphasis on the consistency and quality of care. The clear goal is ensuring that all patients truly receive the very best care available, as defined by rigorous scientific studies.
 Contemplation can provide new medical insights (Illustration: Rusty Howson, sososo design) This discrepancy between what patients should be receiving and what patients are actually receiving is the major focus of quality reform, and reflects the new recognition that there are truly preferred approaches—pathways—to guide disease management. These pathways are not meant to represent a rigid algorithm reflexively applied to each patient, but are intended as a summary of the best available data, a useful template to guide further medical decisions. The renewed emphasis on quality has also resulted in a newfound appreciation for the role of experience and repetition in patient care. Study after study has shown that the best physician to treat a particular problem is the one who has treated it the most  [3] .
Benefits of Quality Reform
From its earliest days, medical training was based on an apprenticeship model, in which junior acolytes learned the art from senior practitioners. Even with the evolution of modern medical schools, which offered future physicians a rigorous common training, once doctors entered the real world they essentially did as they pleased. Consequently, there were pronounced differences in approaches to common problems from one clinician to another.There was also little to guarantee that once doctors had hung out their shingle, they were actually competent (and remained competent) to practice their craft. While most physicians remained committed to the general professional standard—do the best that you can for each individual patient— many well-meaning doctors ultimately were not delivering their patients the best care available.More recently, and largely due to the contagious spread of the so-called “business model,” there has been an increased emphasis on the consistency and quality of care. The clear goal is ensuring that all patients truly receive the very best care available, as defined by rigorous scientific studies.This discrepancy between what patients should be receiving and what patients are actually receiving is the major focus of quality reform, and reflects the new recognition that there are truly preferred approaches—pathways—to guide disease management. These pathways are not meant to represent a rigid algorithm reflexively applied to each patient, but are intended as a summary of the best available data, a useful template to guide further medical decisions.The renewed emphasis on quality has also resulted in a newfound appreciation for the role of experience and repetition in patient care. Study after study has shown that the best physician to treat a particular problem is the one who has treated it the most  [3] .What Gets Lost: Innovation The great paradox here is that the same reforms that are improving our current care may also be endangering our future health. As medicine has become more standardized and increasingly regulated, it turns out there is much less room for innovation. The spirited pursuit of the unknown—so long a defining quality of medicine—now seems seriously endangered. The new world of rapid throughput and endless documentation provides little time to reflect upon important clinical problems and consider fresh approaches. If anything, thinking about a patient or a question too much is now implicitly discouraged because it slows doctors down; contemplation is bad for productivity. Academic medical centers like our own have played a particularly important role in the history of medical discovery; the hallmark of these institutions is our commitment to thinking and reflecting about the patients we see, patients who are often extremely sick and whose management is exceptionally complex. Unfortunately, many of the measurements now used by insurance companies to assess quality pay little attention—if any at all—to the complexity of a patient's illness, or to the importance of spending time trying to define the underlying malady. Insurance companies' major concern seems to be how fast a patient is “processed,” ideally with as few tests as possible. These measures provide no mechanism for distinguishing between the addled physician who inappropriately orders every test that springs to mind, and the reflective physician who is trying to get to the bottom of a patient's complaint, rather than simply throw a Band-Aid over the symptoms  [4] . Situated on the front lines, clinicians have a unique opportunity to provide new medical insights and to identify critical, unanswered questions. Classic examples include Archibald Garrod, a British physician whose desire to understand why a patient produced black urine led to the hypothesis that diseases can result from defective metabolic enzymes, and Fuller Albright, a clinical investigator at Harvard whose thoughtful approach to his patients yielded insights that revolutionized the field of endocrinology. More recently, the astute clinical observations of UCLA immunologist Michael Gottlieb resulted in the original description of the Acquired Immune Deficiency Syndrome (AIDS) in 1981  [5] .
What Gets Lost: Innovation
The great paradox here is that the same reforms that are improving our current care may also be endangering our future health. As medicine has become more standardized and increasingly regulated, it turns out there is much less room for innovation. The spirited pursuit of the unknown—so long a defining quality of medicine—now seems seriously endangered. The new world of rapid throughput and endless documentation provides little time to reflect upon important clinical problems and consider fresh approaches. If anything, thinking about a patient or a question too much is now implicitly discouraged because it slows doctors down; contemplation is bad for productivity.Academic medical centers like our own have played a particularly important role in the history of medical discovery; the hallmark of these institutions is our commitment to thinking and reflecting about the patients we see, patients who are often extremely sick and whose management is exceptionally complex. Unfortunately, many of the measurements now used by insurance companies to assess quality pay little attention—if any at all—to the complexity of a patient's illness, or to the importance of spending time trying to define the underlying malady. Insurance companies' major concern seems to be how fast a patient is “processed,” ideally with as few tests as possible. These measures provide no mechanism for distinguishing between the addled physician who inappropriately orders every test that springs to mind, and the reflective physician who is trying to get to the bottom of a patient's complaint, rather than simply throw a Band-Aid over the symptoms  [4] .Situated on the front lines, clinicians have a unique opportunity to provide new medical insights and to identify critical, unanswered questions. Classic examples include Archibald Garrod, a British physician whose desire to understand why a patient produced black urine led to the hypothesis that diseases can result from defective metabolic enzymes, and Fuller Albright, a clinical investigator at Harvard whose thoughtful approach to his patients yielded insights that revolutionized the field of endocrinology. More recently, the astute clinical observations of UCLA immunologist Michael Gottlieb resulted in the original description of the Acquired Immune Deficiency Syndrome (AIDS) in 1981  [5] .Preserving Creativity in Medicine But where are these types of insights going to come from today? It seems difficult to imagine that a medical care environment characterized by staccato-quick patient visits covering an ever-increasing number of compulsory topics will support or encourage such reflection and innovation. Our failure to nourish and sustain inquisitive physicians seems particularly tragic because medicine has traditionally attracted some of our brightest and most imaginative individuals. Even at the height of the dot-com boom, for example, there were still more medical school applicants than there were spaces to train them. But if current trends continue, many of these creative minds will head elsewhere, while those who stay will risk becoming stultified by repetitious routine. Several medical schools and a handful of foundations have recognized this emerging problem, and have initiated programs aimed at sparking curiosity in young doctors (our own school's program is called the PASTEUR initiative—see  www.pasteur.hms.harvard.edu )  [6] . But as well-intentioned as these efforts are, simply changing the curriculum isn't likely to fix the underlying problem. Unless ever-savvy medical students perceive that inquisitive thinking is truly valued in clinical medicine, and unless exasperated physicians are inspired to believe that they have the ability to change some aspect of the way medicine is practiced, nothing is going to change. We may lose the best hope we have of defeating the terrible diseases that now plague us. Even as we strive to improve the consistency of care—and striving is clearly a very good idea—we must continue to cultivate novelty and originality, rather than penalize it. Imagination is perhaps the most essential trait that medicine, and medical insurers, must again learn to recognize and reward. Even with the best algorithms and the brightest computers, the future of health care ultimately depends upon the creativity of the hardy men and women still entrusted with its delivery.
Preserving Creativity in Medicine
But where are these types of insights going to come from today? It seems difficult to imagine that a medical care environment characterized by staccato-quick patient visits covering an ever-increasing number of compulsory topics will support or encourage such reflection and innovation. Our failure to nourish and sustain inquisitive physicians seems particularly tragic because medicine has traditionally attracted some of our brightest and most imaginative individuals. Even at the height of the dot-com boom, for example, there were still more medical school applicants than there were spaces to train them. But if current trends continue, many of these creative minds will head elsewhere, while those who stay will risk becoming stultified by repetitious routine.Several medical schools and a handful of foundations have recognized this emerging problem, and have initiated programs aimed at sparking curiosity in young doctors (our own school's program is called the PASTEUR initiative—see  www.pasteur.hms.harvard.edu )  [6] . But as well-intentioned as these efforts are, simply changing the curriculum isn't likely to fix the underlying problem. Unless ever-savvy medical students perceive that inquisitive thinking is truly valued in clinical medicine, and unless exasperated physicians are inspired to believe that they have the ability to change some aspect of the way medicine is practiced, nothing is going to change. We may lose the best hope we have of defeating the terrible diseases that now plague us.Even as we strive to improve the consistency of care—and striving is clearly a very good idea—we must continue to cultivate novelty and originality, rather than penalize it. Imagination is perhaps the most essential trait that medicine, and medical insurers, must again learn to recognize and reward. Even with the best algorithms and the brightest computers, the future of health care ultimately depends upon the creativity of the hardy men and women still entrusted with its delivery.


Background While sleep disturbance is widespread in schizophrenia it is less clear whether sleep disturbance is uniquely related to impaired coping and perceived quality of life.
Background
While sleep disturbance is widespread in schizophrenia it is less clear whether sleep disturbance is uniquely related to impaired coping and perceived quality of life.Methods We simultaneously assessed sleep quality, symptoms, and coping in 29 persons with schizophrenia or schizoaffective disorder in a post acute phase of illness. Assessment instruments included the Pittsburgh Sleep Quality Index; the Positive and Negative Symptom Scale; the Heinrichs Quality of Life Scale; and the Ways of Coping Scale. Multiple regressions were performed predicting quality of life and coping from sleep quality controlling for age and symptom severity. On a subset of seven subjects non-dominant wrist actigraphy was used as an objective check of their self-reported poor sleep.
Methods
We simultaneously assessed sleep quality, symptoms, and coping in 29 persons with schizophrenia or schizoaffective disorder in a post acute phase of illness. Assessment instruments included the Pittsburgh Sleep Quality Index; the Positive and Negative Symptom Scale; the Heinrichs Quality of Life Scale; and the Ways of Coping Scale. Multiple regressions were performed predicting quality of life and coping from sleep quality controlling for age and symptom severity. On a subset of seven subjects non-dominant wrist actigraphy was used as an objective check of their self-reported poor sleep.Results Analyses revealed that poor sleep quality predicted low quality of life (r = -0.493; p = .022) and reduced preference for employing positive reappraisal when facing a stressor (r = -0.0594; p = 0.0012). Actigraphy confirmed poor sleep quality in a subset of subjects. They had shorter sleep duration (p < .0005), shorter average sleep episodes (p < .005) and more episodes of long awakening (p < 0.05) than community norms.
Results
Analyses revealed that poor sleep quality predicted low quality of life (r = -0.493; p = .022) and reduced preference for employing positive reappraisal when facing a stressor (r = -0.0594; p = 0.0012). Actigraphy confirmed poor sleep quality in a subset of subjects. They had shorter sleep duration (p < .0005), shorter average sleep episodes (p < .005) and more episodes of long awakening (p < 0.05) than community norms.Conclusion The results are consistent with the hypotheses that poor sleep may play a unique role in sustaining poor quality of life and impaired coping in patients with schizophrenia. These associations may hold for community controls as well.
Conclusion
The results are consistent with the hypotheses that poor sleep may play a unique role in sustaining poor quality of life and impaired coping in patients with schizophrenia. These associations may hold for community controls as well.

Background Many persons with schizophrenia report chronically disturbed sleep [ 1 , 2 ]. Independent of the phase of illness, sleep disturbance documented by polysomnography include: difficulties falling asleep, awakening too early and being unable to go back to sleep, a preference for being awake during the evening, reduced deep or slow-wave sleep (the most restorative stage of sleep), and short REM latencies [ 3 - 6 ]. In addition to being a source of distress, various forms of sleep disturbance have also been linked to heightened levels of thought disorder [ 7 ] and symptoms of excitement [ 8 ] and may portend relapse [ 9 ]. While sleep disturbance appears widespread in schizophrenia and is related to clinical features, less clear is whether it is also related to impaired coping that characterizes the disorder. Is poor sleep quality another factor that uniquely contributes to the difficulties persons with schizophrenia experience coping with stressors, and sustaining relationships and work? There appear to be several reasons to hypothesize that it may. Impaired sleep may make it difficult for persons with schizophrenia to cope with stressors [ 10 ]. Persons with schizophrenia and impaired sleep might feel, for instance, especially exhausted and highly inclined to avoid stressors and have difficulty seeing the positive aspects of daily challenges. Consistent with this, at least one study finds that damaged sleep quality in schizophrenia relates to longer periods of time spent in bed [ 2 ]. With low energy level and need for more time in bed, it seems a matter of intuition that persons might have great difficulty sustaining interpersonal relationships and adapting to the demands of a work setting. Additionally, beyond its effects on coping, we might expect persons with impoverished sleep, irrespective of their symptom level, to have less social and vocational satisfaction than those with better sleep. Indeed, one study indicates that sleep quality is associated with quality of life for patients with schizophrenia [ 11 ]. To examine relationships between sleep quality, coping and quality of life, we simultaneously assessed these domains along with symptom level in a group of patients with chronic schizophrenia and schizoffective disorder in a post acute phase of illness. To assess sleep quality we used the Pittsburgh Sleep Quality Index (PSI [ 12 ]), a standardized self-assessment tool that gauges sleep quality during the past month. We chose the PSI because it has been successfully used in several studies of persons with schizophrenia [ 2 , 11 , 13 , 14 ]. To assess coping we used the Ways of Coping Questionnaire (WCQ), a widely used instrument that measures the relative degree of preference for a number of coping strategies and which is sensitive to the maladaptive coping preferences common to schizophrenia [ 15 ]. To assess symptoms and quality of life, we used two instruments that are the gold standard in schizophrenia research: the Positive and Negative Syndrome Scale (PANSS [ 16 ]) and the Quality of Life Scale (QLS [ 17 ]). We predicted that, controlling for levels of positive and negative symptoms, poorer sleep quality would predict poorer quality of life overall, a greater preference for avoidant coping, and a lesser preference for coping by positive reappraisal. Some doubt the abilities of persons with schizophrenia to report their own sleep patterns accurately. However, a study comparing polysomnography with subjective measures of sleep found that they were highly correlated in a group of patients with chronic schizophrenia [ 18 ]. Similarly, others found that persons with severe mental illness can generally report the quality of their lives as well as those with other non-psychiatric illnesses [ 19 , 20 ]. In addition, we wanted to know if actigraphy is an effective way of demonstrating sleep problems in the post-acute phase of schizophrenia. To address this question, we used actigraphy to monitor sleep patterns in a subset of this patient population. Wrist actigraphy consists of monitoring locomotor activity with a motion sensor slightly bigger than a wrist-watch that is worn on the non-dominant wrist. It is a common method used to assess sleep [ 21 ]. Actigraphy is valid and reliable for evaluating sleep patterns in insomnia, in diagnosing circadian rhythm disorders, and in assessing sleep in subjects who are unlikely to tolerate polysomnography [ 22 ]. There are small studies that suggest the feasibility of using actigraphy in assessments of sleep disturbance in patients with schizophrenia [ 23 , 24 ].
Background
Many persons with schizophrenia report chronically disturbed sleep [ 1 , 2 ]. Independent of the phase of illness, sleep disturbance documented by polysomnography include: difficulties falling asleep, awakening too early and being unable to go back to sleep, a preference for being awake during the evening, reduced deep or slow-wave sleep (the most restorative stage of sleep), and short REM latencies [ 3 - 6 ]. In addition to being a source of distress, various forms of sleep disturbance have also been linked to heightened levels of thought disorder [ 7 ] and symptoms of excitement [ 8 ] and may portend relapse [ 9 ].While sleep disturbance appears widespread in schizophrenia and is related to clinical features, less clear is whether it is also related to impaired coping that characterizes the disorder. Is poor sleep quality another factor that uniquely contributes to the difficulties persons with schizophrenia experience coping with stressors, and sustaining relationships and work? There appear to be several reasons to hypothesize that it may. Impaired sleep may make it difficult for persons with schizophrenia to cope with stressors [ 10 ]. Persons with schizophrenia and impaired sleep might feel, for instance, especially exhausted and highly inclined to avoid stressors and have difficulty seeing the positive aspects of daily challenges. Consistent with this, at least one study finds that damaged sleep quality in schizophrenia relates to longer periods of time spent in bed [ 2 ]. With low energy level and need for more time in bed, it seems a matter of intuition that persons might have great difficulty sustaining interpersonal relationships and adapting to the demands of a work setting. Additionally, beyond its effects on coping, we might expect persons with impoverished sleep, irrespective of their symptom level, to have less social and vocational satisfaction than those with better sleep. Indeed, one study indicates that sleep quality is associated with quality of life for patients with schizophrenia [ 11 ].To examine relationships between sleep quality, coping and quality of life, we simultaneously assessed these domains along with symptom level in a group of patients with chronic schizophrenia and schizoffective disorder in a post acute phase of illness. To assess sleep quality we used the Pittsburgh Sleep Quality Index (PSI [ 12 ]), a standardized self-assessment tool that gauges sleep quality during the past month. We chose the PSI because it has been successfully used in several studies of persons with schizophrenia [ 2 , 11 , 13 , 14 ]. To assess coping we used the Ways of Coping Questionnaire (WCQ), a widely used instrument that measures the relative degree of preference for a number of coping strategies and which is sensitive to the maladaptive coping preferences common to schizophrenia [ 15 ]. To assess symptoms and quality of life, we used two instruments that are the gold standard in schizophrenia research: the Positive and Negative Syndrome Scale (PANSS [ 16 ]) and the Quality of Life Scale (QLS [ 17 ]). We predicted that, controlling for levels of positive and negative symptoms, poorer sleep quality would predict poorer quality of life overall, a greater preference for avoidant coping, and a lesser preference for coping by positive reappraisal.Some doubt the abilities of persons with schizophrenia to report their own sleep patterns accurately. However, a study comparing polysomnography with subjective measures of sleep found that they were highly correlated in a group of patients with chronic schizophrenia [ 18 ]. Similarly, others found that persons with severe mental illness can generally report the quality of their lives as well as those with other non-psychiatric illnesses [ 19 , 20 ].In addition, we wanted to know if actigraphy is an effective way of demonstrating sleep problems in the post-acute phase of schizophrenia. To address this question, we used actigraphy to monitor sleep patterns in a subset of this patient population. Wrist actigraphy consists of monitoring locomotor activity with a motion sensor slightly bigger than a wrist-watch that is worn on the non-dominant wrist. It is a common method used to assess sleep [ 21 ]. Actigraphy is valid and reliable for evaluating sleep patterns in insomnia, in diagnosing circadian rhythm disorders, and in assessing sleep in subjects who are unlikely to tolerate polysomnography [ 22 ]. There are small studies that suggest the feasibility of using actigraphy in assessments of sleep disturbance in patients with schizophrenia [ 23 , 24 ].Methods Participants All subjects met the Structured Clinical Interview for DSM IV (SCID [ 25 ]) diagnosis DSM-IV-TR [ 26 ] criteria for schizophrenia or schizoaffective disorder. All were in the post acute phase of illness; with no hospitalizations or medication changes for at least one month. Most were patients with chronic schizophrenia who were in a VA day treatment setting. All patient-subjects participated in an informed consent procedure and signed informed consent forms for this research. A tabulated summary of the participants' characteristics is in Table  1 . Table 1 Subject symptoms and demographics Subject Characteristics Mean (S.D.) Subjects Enrolled 29   Men 27   Women 2 Age 48 (7) Education 12 (2) Age at first hospitalization 25 (9) Number of hospitalizations 12 (6) SCID diagnosis   Schizophrenia 23   Schizoaffective disorder 6 PANSS components   Positive 19 (5)   Negative 19 (6)   Cognitive 19 (5)   Emotional 13 (4)   Excitement/Hostility 9 (3) Medication (CPZ equiv.) 755 (752) Instruments Actigraphy Sensors (Model # 24.000, Ambulatory Monitoring Inc, Ardsley, NY) slightly bigger than a wristwatch were worn by subjects on their non-dominant wrists for 21 days. Actigraphic logs of the non-dominant arm have a high correlation with gross locomotor activity [ 27 ]. Actigraphy is validated and reliable for evaluating sleep patterns [ 22 ]. The data from each actigraph was processed by the software included with the actigraphic monitors. Pittsburgh Sleep Quality Index (PSI) The PSI is an effective instrument used to measure the quality and patterns of sleep. It differentiates "poor" from "good" sleep by measuring seven subscales: Subjective Sleep Quality, Sleep Latency, Sleep Duration, Habitual Sleep Efficiency, Sleep Disturbances, Use of Sleeping Medication, and Daytime Dysfunction over the last month. The client self-rates each of these seven areas of sleep by answering nine questions. Scoring of answers is based on a zero to three scale, and a score of three reflects the negative extreme on the Likert Scale. A global sum of "5" or greater indicates a "poor" sleeper. The PSI has internal consistency and a reliability coefficient (Cronbach's alpha) of 0.83 for its seven components. Numerous studies using the PSI have supported high validity and reliability. Positive and Negative Syndrome Scale (PANSS) The PANSS is a 30 item rating scale completed by clinically-trained research staff at the conclusion of chart review and a semi-structured interview. For the purposes of this study the five PANSS factor analytically derived components are used: Positive, Negative, Cognitive, Excitement and Emotional discomfort [ 28 ]. Quality of Life Scale (QLS [ 29 ]) The tool is a 21 item scale completed by clinically trained staff after a semi-structured interview and chart review that assesses quality of life. Items are scored on a 7-point scale with higher ratings representing higher levels of satisfaction. Items tap a range of essential aspects of psychosocial interactions incorporating four subscales: Interpsychic Foundations; Occupational Functions; Commonplace Objects; and Activities and Interpersonal Relationships. For the purposes of this study we used the sum of all items as an index of overall quality of life. Interrater reliability for this instrument has been reported to range between 0.85 and 0.93 [ 15 ]. Ways of Coping Questionnaire (WCQ [ 30 ]) The WCQ is a self-report instrument that asks participants to call to mind a recent stressor and then rate how often they have used 66 different behaviours to cope with that stressor. Scale scores are additively derived from individual items and divided by a total score to provide a relative score. This relative score reflects participants' relative preferences among a set of discrete coping strategies. Relative scores are generally preferable because, among other things, they control for response bias. For the purposes of this study we calculated the relative scores for two subscales: "Escape Avoidance," and "Positive Reappraisal." Escape Avoidance describes wishful thinking and behavioural efforts to actively escape or avoid the problem and includes items such as: "I refused to believe it had happened" and "I wished the situation would go away or be over with." Positive Reappraisal describes efforts to create positive meaning by focusing on personal growth and includes items such as: "I changed or grew as a person in a good way" and "I found new faith." Internal consistency assessed using Cronbach's alpha have been reported to range from 0.61 to 0.79. Procedures Following informed consent participants were administered the PSI. PANSS, QLS, and WCQ were completed within the previous month for another study of the effects of personality on function in schizophrenia. Diagnosis was determined using the SCID. Ratings of sleep quality were elicited by a research assistant blind to the results of the PANSS, QLS and WCQ. We fitted a subset of patients with actigraphs that they wore for 21 days. Statistical analysis The statistical analyses were Pearson correlations and Mixed Models analyses in SAS ®  software. We also repeated the correlations for patients with schizophrenia separate from the patients with schizoaffective disorder.
Methods
Participants All subjects met the Structured Clinical Interview for DSM IV (SCID [ 25 ]) diagnosis DSM-IV-TR [ 26 ] criteria for schizophrenia or schizoaffective disorder. All were in the post acute phase of illness; with no hospitalizations or medication changes for at least one month. Most were patients with chronic schizophrenia who were in a VA day treatment setting. All patient-subjects participated in an informed consent procedure and signed informed consent forms for this research. A tabulated summary of the participants' characteristics is in Table  1 . Table 1 Subject symptoms and demographics Subject Characteristics Mean (S.D.) Subjects Enrolled 29   Men 27   Women 2 Age 48 (7) Education 12 (2) Age at first hospitalization 25 (9) Number of hospitalizations 12 (6) SCID diagnosis   Schizophrenia 23   Schizoaffective disorder 6 PANSS components   Positive 19 (5)   Negative 19 (6)   Cognitive 19 (5)   Emotional 13 (4)   Excitement/Hostility 9 (3) Medication (CPZ equiv.) 755 (752)
Participants
All subjects met the Structured Clinical Interview for DSM IV (SCID [ 25 ]) diagnosis DSM-IV-TR [ 26 ] criteria for schizophrenia or schizoaffective disorder. All were in the post acute phase of illness; with no hospitalizations or medication changes for at least one month. Most were patients with chronic schizophrenia who were in a VA day treatment setting. All patient-subjects participated in an informed consent procedure and signed informed consent forms for this research. A tabulated summary of the participants' characteristics is in Table  1 .Subject symptoms and demographicsInstruments Actigraphy Sensors (Model # 24.000, Ambulatory Monitoring Inc, Ardsley, NY) slightly bigger than a wristwatch were worn by subjects on their non-dominant wrists for 21 days. Actigraphic logs of the non-dominant arm have a high correlation with gross locomotor activity [ 27 ]. Actigraphy is validated and reliable for evaluating sleep patterns [ 22 ]. The data from each actigraph was processed by the software included with the actigraphic monitors. Pittsburgh Sleep Quality Index (PSI) The PSI is an effective instrument used to measure the quality and patterns of sleep. It differentiates "poor" from "good" sleep by measuring seven subscales: Subjective Sleep Quality, Sleep Latency, Sleep Duration, Habitual Sleep Efficiency, Sleep Disturbances, Use of Sleeping Medication, and Daytime Dysfunction over the last month. The client self-rates each of these seven areas of sleep by answering nine questions. Scoring of answers is based on a zero to three scale, and a score of three reflects the negative extreme on the Likert Scale. A global sum of "5" or greater indicates a "poor" sleeper. The PSI has internal consistency and a reliability coefficient (Cronbach's alpha) of 0.83 for its seven components. Numerous studies using the PSI have supported high validity and reliability. Positive and Negative Syndrome Scale (PANSS) The PANSS is a 30 item rating scale completed by clinically-trained research staff at the conclusion of chart review and a semi-structured interview. For the purposes of this study the five PANSS factor analytically derived components are used: Positive, Negative, Cognitive, Excitement and Emotional discomfort [ 28 ]. Quality of Life Scale (QLS [ 29 ]) The tool is a 21 item scale completed by clinically trained staff after a semi-structured interview and chart review that assesses quality of life. Items are scored on a 7-point scale with higher ratings representing higher levels of satisfaction. Items tap a range of essential aspects of psychosocial interactions incorporating four subscales: Interpsychic Foundations; Occupational Functions; Commonplace Objects; and Activities and Interpersonal Relationships. For the purposes of this study we used the sum of all items as an index of overall quality of life. Interrater reliability for this instrument has been reported to range between 0.85 and 0.93 [ 15 ]. Ways of Coping Questionnaire (WCQ [ 30 ]) The WCQ is a self-report instrument that asks participants to call to mind a recent stressor and then rate how often they have used 66 different behaviours to cope with that stressor. Scale scores are additively derived from individual items and divided by a total score to provide a relative score. This relative score reflects participants' relative preferences among a set of discrete coping strategies. Relative scores are generally preferable because, among other things, they control for response bias. For the purposes of this study we calculated the relative scores for two subscales: "Escape Avoidance," and "Positive Reappraisal." Escape Avoidance describes wishful thinking and behavioural efforts to actively escape or avoid the problem and includes items such as: "I refused to believe it had happened" and "I wished the situation would go away or be over with." Positive Reappraisal describes efforts to create positive meaning by focusing on personal growth and includes items such as: "I changed or grew as a person in a good way" and "I found new faith." Internal consistency assessed using Cronbach's alpha have been reported to range from 0.61 to 0.79.
Instruments
Actigraphy Sensors (Model # 24.000, Ambulatory Monitoring Inc, Ardsley, NY) slightly bigger than a wristwatch were worn by subjects on their non-dominant wrists for 21 days. Actigraphic logs of the non-dominant arm have a high correlation with gross locomotor activity [ 27 ]. Actigraphy is validated and reliable for evaluating sleep patterns [ 22 ]. The data from each actigraph was processed by the software included with the actigraphic monitors.
Actigraphy
Sensors (Model # 24.000, Ambulatory Monitoring Inc, Ardsley, NY) slightly bigger than a wristwatch were worn by subjects on their non-dominant wrists for 21 days. Actigraphic logs of the non-dominant arm have a high correlation with gross locomotor activity [ 27 ]. Actigraphy is validated and reliable for evaluating sleep patterns [ 22 ]. The data from each actigraph was processed by the software included with the actigraphic monitors.Pittsburgh Sleep Quality Index (PSI) The PSI is an effective instrument used to measure the quality and patterns of sleep. It differentiates "poor" from "good" sleep by measuring seven subscales: Subjective Sleep Quality, Sleep Latency, Sleep Duration, Habitual Sleep Efficiency, Sleep Disturbances, Use of Sleeping Medication, and Daytime Dysfunction over the last month. The client self-rates each of these seven areas of sleep by answering nine questions. Scoring of answers is based on a zero to three scale, and a score of three reflects the negative extreme on the Likert Scale. A global sum of "5" or greater indicates a "poor" sleeper. The PSI has internal consistency and a reliability coefficient (Cronbach's alpha) of 0.83 for its seven components. Numerous studies using the PSI have supported high validity and reliability.
Pittsburgh Sleep Quality Index (PSI)
The PSI is an effective instrument used to measure the quality and patterns of sleep. It differentiates "poor" from "good" sleep by measuring seven subscales: Subjective Sleep Quality, Sleep Latency, Sleep Duration, Habitual Sleep Efficiency, Sleep Disturbances, Use of Sleeping Medication, and Daytime Dysfunction over the last month. The client self-rates each of these seven areas of sleep by answering nine questions. Scoring of answers is based on a zero to three scale, and a score of three reflects the negative extreme on the Likert Scale. A global sum of "5" or greater indicates a "poor" sleeper. The PSI has internal consistency and a reliability coefficient (Cronbach's alpha) of 0.83 for its seven components. Numerous studies using the PSI have supported high validity and reliability.Positive and Negative Syndrome Scale (PANSS) The PANSS is a 30 item rating scale completed by clinically-trained research staff at the conclusion of chart review and a semi-structured interview. For the purposes of this study the five PANSS factor analytically derived components are used: Positive, Negative, Cognitive, Excitement and Emotional discomfort [ 28 ].
Positive and Negative Syndrome Scale (PANSS)
The PANSS is a 30 item rating scale completed by clinically-trained research staff at the conclusion of chart review and a semi-structured interview. For the purposes of this study the five PANSS factor analytically derived components are used: Positive, Negative, Cognitive, Excitement and Emotional discomfort [ 28 ].Quality of Life Scale (QLS [ 29 ]) The tool is a 21 item scale completed by clinically trained staff after a semi-structured interview and chart review that assesses quality of life. Items are scored on a 7-point scale with higher ratings representing higher levels of satisfaction. Items tap a range of essential aspects of psychosocial interactions incorporating four subscales: Interpsychic Foundations; Occupational Functions; Commonplace Objects; and Activities and Interpersonal Relationships. For the purposes of this study we used the sum of all items as an index of overall quality of life. Interrater reliability for this instrument has been reported to range between 0.85 and 0.93 [ 15 ].
Quality of Life Scale (QLS [ 29 ])
The tool is a 21 item scale completed by clinically trained staff after a semi-structured interview and chart review that assesses quality of life. Items are scored on a 7-point scale with higher ratings representing higher levels of satisfaction. Items tap a range of essential aspects of psychosocial interactions incorporating four subscales: Interpsychic Foundations; Occupational Functions; Commonplace Objects; and Activities and Interpersonal Relationships. For the purposes of this study we used the sum of all items as an index of overall quality of life. Interrater reliability for this instrument has been reported to range between 0.85 and 0.93 [ 15 ].Ways of Coping Questionnaire (WCQ [ 30 ]) The WCQ is a self-report instrument that asks participants to call to mind a recent stressor and then rate how often they have used 66 different behaviours to cope with that stressor. Scale scores are additively derived from individual items and divided by a total score to provide a relative score. This relative score reflects participants' relative preferences among a set of discrete coping strategies. Relative scores are generally preferable because, among other things, they control for response bias. For the purposes of this study we calculated the relative scores for two subscales: "Escape Avoidance," and "Positive Reappraisal." Escape Avoidance describes wishful thinking and behavioural efforts to actively escape or avoid the problem and includes items such as: "I refused to believe it had happened" and "I wished the situation would go away or be over with." Positive Reappraisal describes efforts to create positive meaning by focusing on personal growth and includes items such as: "I changed or grew as a person in a good way" and "I found new faith." Internal consistency assessed using Cronbach's alpha have been reported to range from 0.61 to 0.79.
Ways of Coping Questionnaire (WCQ [ 30 ])
The WCQ is a self-report instrument that asks participants to call to mind a recent stressor and then rate how often they have used 66 different behaviours to cope with that stressor. Scale scores are additively derived from individual items and divided by a total score to provide a relative score. This relative score reflects participants' relative preferences among a set of discrete coping strategies. Relative scores are generally preferable because, among other things, they control for response bias. For the purposes of this study we calculated the relative scores for two subscales: "Escape Avoidance," and "Positive Reappraisal." Escape Avoidance describes wishful thinking and behavioural efforts to actively escape or avoid the problem and includes items such as: "I refused to believe it had happened" and "I wished the situation would go away or be over with." Positive Reappraisal describes efforts to create positive meaning by focusing on personal growth and includes items such as: "I changed or grew as a person in a good way" and "I found new faith." Internal consistency assessed using Cronbach's alpha have been reported to range from 0.61 to 0.79.Procedures Following informed consent participants were administered the PSI. PANSS, QLS, and WCQ were completed within the previous month for another study of the effects of personality on function in schizophrenia. Diagnosis was determined using the SCID. Ratings of sleep quality were elicited by a research assistant blind to the results of the PANSS, QLS and WCQ. We fitted a subset of patients with actigraphs that they wore for 21 days.
Procedures
Following informed consent participants were administered the PSI. PANSS, QLS, and WCQ were completed within the previous month for another study of the effects of personality on function in schizophrenia. Diagnosis was determined using the SCID. Ratings of sleep quality were elicited by a research assistant blind to the results of the PANSS, QLS and WCQ. We fitted a subset of patients with actigraphs that they wore for 21 days.Statistical analysis The statistical analyses were Pearson correlations and Mixed Models analyses in SAS ®  software. We also repeated the correlations for patients with schizophrenia separate from the patients with schizoaffective disorder.
Statistical analysis
The statistical analyses were Pearson correlations and Mixed Models analyses in SAS ®  software. We also repeated the correlations for patients with schizophrenia separate from the patients with schizoaffective disorder.Results Mean scores ± SD on the tests were: Quality of Life total 51.73 ± 16.16; Pittsburgh Sleep Quality Index 11.6 ± 4.57; Ways of Coping Questionnaire subscales: "Escape Avoidance," 0.138 ± 0.062 and "Positive Reappraisal" 0.125 ± 0.079. There was no correlation between QLS and "Escape Avoidance" scores, but a modest positive correlation between QLS and "Positive Reappraisal" (r = 0.421, p = 0.021). To examine the associations between sleep and quality of life we next performed partial correlations, using the PSI total score to predict QLS total score and QLS subscores with age and positive and negative component scores as covariates. Similarly, we used PSI subscores to predict QLS total score. Results revealed that poor sleep was related to poor quality of life (total PSI vs total QLS, r = -0.493; p = .022). The PSI accounted for 24% of the variance in QLS. Total PSI did not correlate with any of the QLS subscores. The PSI subscores: "Subjective Sleep Quality", "Sleep Duration", and "Sleep Disturbances" correlated with total QLS at p < 0.05 but none were significant after making the Bonferroni correction for multiple comparisons. To examine the associations between sleep and coping style we next performed partial correlations, using the PSI total score to predict WCQ Escape Avoidance, and WCQ Positive Reappraisal score with age and positive and negative component scores as covariates. Results revealed that poor sleep was related to a reduced preference for Positive Reappraisal (r = -0.594; p = 0.0012). Sleep quality was found to be unrelated to Escape Avoidance. The PSI accounted for over 37 % of the variance in coping. Patients with schizoaffective disorder had worse sleep as measured by the PSI than did patients with schizophrenia (13.7 ± 4.4 versus 9.7 ± 4.7; t-test, p = 0.03). The two groups did not differ in total scores of the QLS or WCQ. The correlations between total PSI and total QLS, and between total PSI and Positive Reappraisal for patients with schizophrenia were significant (r = -0.516; p = 0.039 and r = -0.645; p = 0.006 respectively). The same correlations were not significant for patients with schizoaffective disorder. Seven participants with schizophrenia accepted the activity monitors and were willing to wear them continually for up to 3 weeks. Seven patients completed actigraphic monitoring, and the actigraphic results are in Table  2 . Actigraphy verified that participants with schizophrenia had less overall sleep and more interrupted sleep than published community norms. Table 2 Sleep measures for subject subset and controls* Sleep Measure Means Patients Controls Units Participants 7 >200 Sleep Duration 1359  c 1440 min/d Sleep Proportion 25 33 % of d # of Long Awake Episodes 10.2  a 6.7 ea d Mean Sleep Episode 28  b 60 min Longest Sleep Episode 105  c 231 min *Controls data provided by Ambulatory Monitoring a  = p < .05;  b  = p < .005;  c  = p < .0005
Results
Mean scores ± SD on the tests were: Quality of Life total 51.73 ± 16.16; Pittsburgh Sleep Quality Index 11.6 ± 4.57; Ways of Coping Questionnaire subscales: "Escape Avoidance," 0.138 ± 0.062 and "Positive Reappraisal" 0.125 ± 0.079. There was no correlation between QLS and "Escape Avoidance" scores, but a modest positive correlation between QLS and "Positive Reappraisal" (r = 0.421, p = 0.021).To examine the associations between sleep and quality of life we next performed partial correlations, using the PSI total score to predict QLS total score and QLS subscores with age and positive and negative component scores as covariates. Similarly, we used PSI subscores to predict QLS total score. Results revealed that poor sleep was related to poor quality of life (total PSI vs total QLS, r = -0.493; p = .022). The PSI accounted for 24% of the variance in QLS. Total PSI did not correlate with any of the QLS subscores. The PSI subscores: "Subjective Sleep Quality", "Sleep Duration", and "Sleep Disturbances" correlated with total QLS at p < 0.05 but none were significant after making the Bonferroni correction for multiple comparisons.To examine the associations between sleep and coping style we next performed partial correlations, using the PSI total score to predict WCQ Escape Avoidance, and WCQ Positive Reappraisal score with age and positive and negative component scores as covariates. Results revealed that poor sleep was related to a reduced preference for Positive Reappraisal (r = -0.594; p = 0.0012). Sleep quality was found to be unrelated to Escape Avoidance. The PSI accounted for over 37 % of the variance in coping.Patients with schizoaffective disorder had worse sleep as measured by the PSI than did patients with schizophrenia (13.7 ± 4.4 versus 9.7 ± 4.7; t-test, p = 0.03). The two groups did not differ in total scores of the QLS or WCQ. The correlations between total PSI and total QLS, and between total PSI and Positive Reappraisal for patients with schizophrenia were significant (r = -0.516; p = 0.039 and r = -0.645; p = 0.006 respectively). The same correlations were not significant for patients with schizoaffective disorder.Seven participants with schizophrenia accepted the activity monitors and were willing to wear them continually for up to 3 weeks. Seven patients completed actigraphic monitoring, and the actigraphic results are in Table  2 . Actigraphy verified that participants with schizophrenia had less overall sleep and more interrupted sleep than published community norms.Sleep measures for subject subset and controls*Sleep Measure MeansPatientsControlsUnits*Controls data provided by Ambulatory Monitoringa  = p < .05;  b  = p < .005;  c  = p < .0005Discussion The results are consistent with the hypothesis that poor quality sleep that typically characterizes schizophrenia may have a powerful impact on both patients' perception of their quality of life and their ability to cope with stress. Independent of age and symptoms, poorer sleep quality predicted poorer quality of life and greater difficulties appraising stressors in a positive light. This may suggest that among the deficits accompanying schizophrenia, poor sleep is often underappreciated. Impaired sleep may erode the ability of schizophrenic patients to cope with the routine stress associated with work and interpersonal relationships. Furthermore, chronic sleep deprivation may contribute to anergy that impairs attendance and work performance. Since the found associations are independent of symptom level they may be trait variables. These findings are consistent with polysomnographic studies of sleep in schizophrenia which show that many sleep deficits that are not dependent on the acuity of illness [ 3 - 7 ]. The findings are also consistent with a prior study of sleep quality and quality of life in patient with schizophrenia [ 11 ]. We had an insufficient number of participants to confirm a correlation between PSI subscores and total Quality of Life. The negative relationship between complaints of poor sleep quality and Preference for coping by Positive Reappraisal remained significant when the confounding effects of symptom acuity and age were partialled from the correlation matrix. One interpretation is that chronically disturbed sleep may erode both the ability to find positive meaning and the desire to achieve personal growth. Given the correlative nature of the data analysis, however, it is not possible to infer causality. It may be that poor coping or poor quality of life lead to greater difficulties sleeping or that another unmeasured variable may account for the relationships. We plan future longitudinal studies that may uncover if sleep changes typically precede or follow changes in either coping or quality of life. There are other limitations to this study; most participants were male and in their 40s. Further experiments will be needed which include females and males in earlier phases of illness. The association of disturbed sleep and both quality of life and coping may hold for community controls as well.
Discussion
The results are consistent with the hypothesis that poor quality sleep that typically characterizes schizophrenia may have a powerful impact on both patients' perception of their quality of life and their ability to cope with stress. Independent of age and symptoms, poorer sleep quality predicted poorer quality of life and greater difficulties appraising stressors in a positive light. This may suggest that among the deficits accompanying schizophrenia, poor sleep is often underappreciated. Impaired sleep may erode the ability of schizophrenic patients to cope with the routine stress associated with work and interpersonal relationships. Furthermore, chronic sleep deprivation may contribute to anergy that impairs attendance and work performance. Since the found associations are independent of symptom level they may be trait variables.These findings are consistent with polysomnographic studies of sleep in schizophrenia which show that many sleep deficits that are not dependent on the acuity of illness [ 3 - 7 ]. The findings are also consistent with a prior study of sleep quality and quality of life in patient with schizophrenia [ 11 ]. We had an insufficient number of participants to confirm a correlation between PSI subscores and total Quality of Life.The negative relationship between complaints of poor sleep quality and Preference for coping by Positive Reappraisal remained significant when the confounding effects of symptom acuity and age were partialled from the correlation matrix. One interpretation is that chronically disturbed sleep may erode both the ability to find positive meaning and the desire to achieve personal growth. Given the correlative nature of the data analysis, however, it is not possible to infer causality. It may be that poor coping or poor quality of life lead to greater difficulties sleeping or that another unmeasured variable may account for the relationships. We plan future longitudinal studies that may uncover if sleep changes typically precede or follow changes in either coping or quality of life.There are other limitations to this study; most participants were male and in their 40s. Further experiments will be needed which include females and males in earlier phases of illness. The association of disturbed sleep and both quality of life and coping may hold for community controls as well.Conclusion These findings may have important clinical implications. If poor sleep quality is indeed a critical factor in quality of life and coping impairments in schizophrenia, clinicians will need to focus on and aggressively treat sleep problems. Specific treatments could include training in sleep hygiene with a focus on regular waking and sleep times, avoiding naps, morning bright light, evening melatonin, or other hypnotic agents. Improved sleep may lead to improved ability to cope with stress, and increased energy. These would improve the quality of life and coping in patients with schizophrenia.
Conclusion
These findings may have important clinical implications. If poor sleep quality is indeed a critical factor in quality of life and coping impairments in schizophrenia, clinicians will need to focus on and aggressively treat sleep problems. Specific treatments could include training in sleep hygiene with a focus on regular waking and sleep times, avoiding naps, morning bright light, evening melatonin, or other hypnotic agents. Improved sleep may lead to improved ability to cope with stress, and increased energy. These would improve the quality of life and coping in patients with schizophrenia.Competing interests The author(s) declare that they have no competing interests.
Competing interests
The author(s) declare that they have no competing interests.Authors' contributions JH participated in the design and coordination of the study and performed the statistical analysis and helped to draft the manuscript. PL conceived of the study and participated in its design and helped to draft the manuscript. AM participated in the design of the study and helped to draft the manuscript.
Authors' contributions
JH participated in the design and coordination of the study and performed the statistical analysis and helped to draft the manuscript. PL conceived of the study and participated in its design and helped to draft the manuscript. AM participated in the design of the study and helped to draft the manuscript.Pre-publication history The pre-publication history for this paper can be accessed here:
Pre-publication history
The pre-publication history for this paper can be accessed here: