CLINICAL HANDBOOK OF SCHIZOPHRENIA

582 VIII. SPECIAL TOPICScovering patient with schizophrenia: medical care, human relationships, material qualityof life, communication and transport services, work and work conditions, safety, knowledge,education, leisure and recreation, and inner experience (May, 1986). Competencymodels, on the other hand, view people as active agents who govern their own lives. Thecore variables of competency models are personal autonomy (Mercier & King, 1994),and self-esteem and self-efficacy (Arns & Linney, 1993).At least two further concepts of quality of life found in the psychiatric literature canbe summarized as the “combined approach” and “adaptive functioning models.” In thecombined approach, both social and psychological indicators are taken into account. Thebest-known combined approach model was designed by Lehman (1983) and consideredquality of life a subjective matter, reflected in a sense of global well-being. In this model,quality-of-life experience is reflected by personal characteristics (e.g., age and sex), objectiveindicators in various domains of life, and subjective quality of life in the same life domains.The objective indicators are external life conditions, such as income, housing, andaccess to the community; whereas subjective quality of life represents the individual’s appraisalof these conditions and uses mostly satisfaction constructs. The domains includedin the combined approach are living situation, family, social relations, leisure, work, law,safety, finances, and health.In adaptive functioning models, importance is given to individual satisfaction in relationto social expectations; a reasonable or high quality of life is dependent on the degreeto which patients can meet the demands of life and achieve fulfillment of needs and findsatisfaction. An example of an adaptive functioning model is that of Baker and Intagliata(1982), in which quality of life is a measure of the environmental system (social indicators),the experienced environment (psychological indicators), the biopsychological system(health, well-being, and needs), and behavior (self-management and adaptation).Both the experienced environment and the biopsychological system are within the person,and comparisons (against standards/levels of adaptation) are made between both thesefoci.Different concepts of quality of life exist, and no universally accepted unitary concepthas emerged in the last two decades of extensive research in psychiatry. This helpskeep the construct of quality of life open, with lively debate on the issue. The consensus,however, is that quality of life is multidimensional, and that it encompasses objective andsubjective indicators, as well as health- and non-health-related domains. It is this combinationof indicators and domains that makes quality of life a measure both useful andchallenging as a specific health outcome.OBJECTIVE AND SUBJECTIVE INDICATORSOver the last two decades, the trend has moved from more objectively defined quality-oflifeconcepts toward understanding quality of life as largely determined by the patient’ssubjective experiences of life and life conditions. Patients’ subjective perceptions of theirquality of life appear linked to their personal subjective evaluation of life events and circumstances,and to the inevitable psychological burden imposed by the often-debilitatingconsequences of schizophrenia. An understanding of the relationship between the objectiveand subjective indicators may, however, be required to make an informed decision,when necessary, on which quality-of-life measure to choose.Although objective and subjective indicators reflect aspects of quality of life, theassociation between the objective and subjective indicators is reported to be weak tomoderate at best, with correlations ranging from .04 to .57, suggesting that they measure