Copyright Blackwell Munksgaard 2003

Acta Psychiatr Scand 2003: 108: 134143

Printed in UK. All rights reserved

ACTA PSYCHIATRICA
SCANDINAVICA
ISSN 0001-690X

Personality and self-variables: important

determinants of subjective quality of life
in schizophrenia out-patients
Eklund M, Backstrom M, Hansson L. Personality and self-variables:
important determinants of subjective quality of life in schizophrenia
out-patients.
Acta Psychiatr Scand 2003: 108: 134143. Blackwell Munksgaard 2003.
Objective: To investigate factors determining severely mentally ill
patients self-rated quality of life. The study hypothesized that
objective life circumstances, personality, self-variables, and
psychopathology would be determinants of quality of life.
Method: A total of 117 individuals with schizophrenia and related
disorders were investigated. Structural equation modelling was used to:
1) investigate if one or more subfactors best described the covariance
within each potential determinant and quality of life, 2) explore the
relations between all variables and factors extracted in step 1.
Results: A multi-factorial model indicated that a self-factor and two
psychopathology factors worked as mediators of self-rated quality of
life, in turn composed of an internal and an external aspect. Personality
dimensions and objective life circumstances accounted directly or
indirectly for substantial parts of quality of life.
Conclusion: The relative importance of individual characteristics and
objective indices was shown. Trait-like properties, such as the selffactor and personality, explained most of the variation in self-rated
quality of life.

Introduction

Clients ratings of their quality of life have attracted increasing interest in psychiatric care and
clinical research in recent decades. The reasons
for this are manifold, but one important motive
has been the ambition to apply a more holistic
perspective to treatment, rehabilitation, and evaluation of treatment outcome. The focus on quality
of life can contribute to illuminating the broad
impact mental illness has on peoples life situation
and their needs. Although ratings of quality of life
have been widely used for dierent purposes in the
eld of mental health there is as yet no consensus
about which factors underlie peoples ratings of
their quality of life, and thus limited knowledge
about which elements bring good satisfaction.
There is some consensus that objective life
circumstances, such as housing conditions, civil
status, and social network, account for about 10
15% in ratings of subjective quality of life (14).
134

M. Eklund1, M. Bckstrm2,
L. Hansson3
1
Department of Clinical Neuroscience, Division of
Occupational Therapy, Lund University, Lund, Sweden,
2
Department of Psychology, Lund University, Lund,
Sweden and 3Department of Clinical Neuroscience,
Division of Psychiatry, Lund University Hospital, Lund,
Sweden

Key words: quality of life; schizophrenia; selfpsychology; personality; psychopathology;

socioeconomic factors
Mona Eklund PhD, Department of Clinical Neuroscience,
Division of Occupational Therapy, Lund University,
PO Box 157, SE-221 00 Lund, Sweden
E-mail: mona.eklund@arb.lu.se
Accepted for publication January 29, 2003

Investigations of relationships between psychopathology and quality of life have indicated some
associations, especially with depressive symptoms
and anxiety (510). Concerning positive and negative psychotic symptoms, the picture is inconclusive, but several researchers have found
relationships between negative symptoms and
quality of life. Norman et al. (11) found that a
quality of life measure that tapped decits correlated with both negative and positive symptoms
and level of functioning, while subjective wellbeing
was related primarily to positive symptoms. Thus,
the ambiguous picture might be due to use of
dierent quality of life measures. Other factors
found to be related to quality of life are more traitlike characteristics of the individual, like personality structure, mastery, autonomy, perceived
control, sense of coherence, self-ecacy, and selfesteem (10, 1216).
Zissi et al. (17) explored a model that tried to
explain variation in quality of life as dependent

Determinants of quality of life

on a complex of relationships between objective
indicators and quality of life mediators, such as a
self-factor and autonomy. They found empirical
support for a link between the mediators and
subjective quality of life. No direct relationships
were found between objective quality of life indicators and subjective quality of life, but there were
some relationships between objective indicators
and the mediators. Another study, testing a model
based on latent variables, found that autonomy
contributed to quality of life, while diagnosis, social
contacts, activity, and use of services did not (18). A
recent review of quality of life in severe mental
illness (19) suggested that personal characteristics,
self-constructs, and clinical characteristics may be
mediators, inuencing how objective circumstances
and subjective appraisal determine perceived quality of life. Searching for more complex relationships
in conrmatory factor analyses is a promising
approach when trying to identify important predictors of quality of life, and recent studies have
pointed to the necessity of this approach (3, 20).
Aims of the study

Building upon conrmatory factor analysis, and

with concern to what previous research has indicated, the present study hypothesized that objective
life circumstances (such as housing conditions,
family situation, and employment), personality,
self-factors (sense of coherence, mastery, and selfesteem), and psychopathology (global functioning,
duration of illness, and psychiatric symptoms)
would contribute to severely mentally ill patients
subjective quality of life.

schizoaective disorder according to DSM-IV

(21) and an age of 2055 years were included.
The study was based on informed consent,
and a research Ethics Committee approved the
project.
At the rst unit, all patients with at least one
visit during the past 1-year period were asked to
participate. This procedure identied 119 individuals. A dropout of altogether 45 individuals, who
did not want to participate (n 40) or did not turn
up at the interview (n 5), resulted in a participation rate of 62%. There were no dierences
regarding sex (P 0.545) or age (P 0.457)
between the dropouts and the participants. The
dropout analysis revealed no statistically signicant dierences with respect to diagnostic subgroups of patients (P 0.192).
At the second unit a sample was randomly
selected from a cohort of patients participating in
a longitudinal study (22) using the same inclusion
criteria as in the rst sample, except for age. Of 71
patients fullling the criteria of age between 24
and 55 years, 43 (61%) were included, while 19
were judged by the interviewer not to be able to
full the tasks and eight declined participation.
No dierences were found between participants
and dropouts concerning age, sex, or diagnostic
subgroup.
Tests for dierences between the samples indicated that they did not dier in age (P 0.22), gender
(P 0.26), psychosocial functioning (P 0.062),
and diagnosis (P 0.72), but the second sample
showed less psychopathology (mean 2.3, SD 0.46
and mean 1.8, SD 0.49, respectively; P < 0.001).
Subjects

Material and methods

This study was based on structural equation modelling (SEM), where the general idea is to create
dierent hypothetical models based on competing
theories within a specic eld of research and
investigate which one of them t the data best. One
special case of SEM uses path-analysis to depict
models of causal relations between independent
and dependent variables. In the present study, two
preliminary models with minor variants were compared to nd out which one of them tted the data
best and which one depicted the data in the most
parsimonious way.
Selection procedure

The subjects of this study were recruited from

two out-patient units. Patients with diagnoses of
schizophrenia, schizophreniform disorder, and

The sample consisted of 117 individuals with a

mean age of 42 years, ranging from 20 to 55 years.
There were 44 women (38%) and 73 men (62%).
Most respondents (83%) were native Swedes. Most
subjects were either unmarried (68%) or widowed/
divorced (14%), and had no children (74%). The
most common living accommodation was an
apartment (80%), and 9% of the respondents
lived in group homes. Most of the subjects
currently had a sick or disability pension. Eighteen
individuals (15%) reported having some kind of
employment.
The predominant diagnostic subgroup was
paranoid schizophrenia (48%). The other diagnoses were schizoaective disorder (15%), undierentiated schizophrenia (14%), disorganized
schizophrenia (11%), residual schizophrenia (4%),
schizophreniform disorder (3%), schizophrenia,
not specied (3%), and catatonic schizophrenia
135

Eklund et al.
(1%). At the time of data collection all subjects
were in regular contact with psychiatric services.
Mean age for rst psychiatric hospitalization was
25 years, ranging from 2 to 51 years. Six individuals had never been hospitalized.
Instruments

Quality of life. The Lancashire Quality of Life

Prole (LQOLP) (23), the Swedish version (24),
was used to estimate subjective quality of life. It is
administered as a structured interview and includes
the individuals subjective ratings as well as objective questions concerning nine quality of life
domains: work, leisure, religion, nances, living
situation, safety, family relations, social relations,
and health. The subjective ratings of the quality of
life domains were summarized into an overall
quality of life score. LQOLP has demonstrated
good internal consistency and testretest reliability
(24, 25).
Objective life circumstances. To reect this area the
objective questions regarding the nine life domains
registered in the LQOLP were used, as well as
sociodemographic questions included in the instrument.
Psychopathology. Psychiatric
symptoms
were
assessed by means of the Brief Psychiatric Rating
Scale (BPRS) (26). It consists of 18 items and
allows for analysis into positive, negative, and
depressive symptoms and general psychopathology. Good inter-observer and intra-observer reliability has been demonstrated (26, 27).
Global assessment of functioning (GAF) (21)
was employed to estimate global psychosocial
functioning. It forms a single rating on a
100-point scale, where 100 indicates not only absence
of pathology, but also positive mental health, and
has acceptable reliability and validity (28, 29).
Self-factors. The Sense of Coherence (SOC) scale
(30), which indicates how well a person manages
stress and stays healthy, even in trying circumstances and traumatic experiences, was used in this
study as a self-related aspect. The respondents rate
questions reecting the constructs comprehensibility, manageability, and meaningfulness on a
7-point scale with two anchoring responses (e.g.
never and very often). The instrument has proven
to be valid and reliable (31, 32). A short version
with 13 items, shown to have the same properties
as the original 29-item scale (33), was used.
The self-esteem scale, originally developed by
Rosenberg (34) but also included in the LQOLP,

136

was used to measure another self-aspect. It has

been shown to have acceptable internal consistency
(23).
Perceived control was measured by means of two
constructs mastery and locus of control (LOC).
Mastery (35) is dened as the extent to which
people see themselves as being in control of the
forces that importantly aect their lives (p. 340).
The scale has been found empirically distinct and
to have good internal consistency (36). The LOC
scale, constructed by Rotter (37), refers to whether
an individual perceives reinforcements to be a
function of his own actions (internal [I] control) or
externally determined (external [E] control). The
present study used a variant of the instrument
developed for Sweden (38). The LOC scale has a
fair internal consistency and testretest reliability
(37).
Personality. The personality inventory used was
the Temperament and Character Inventory (TCI)
(39). It rests on a psychobiological model of
personality based on seven dimensions. There are
four temperament factors novelty seeking,
harm avoidance, reward dependence, and persistence which are considered to be stable
throughout life. Three character factors selfdirectedness, cooperativeness, and self-transcendence mature in response to social learning and
life experiences. A Swedish translation (40) of the
short version of TCI, TCI-125 (41), was used.
TCI is a self-report measure, but in this study the
administration mode had to be modied as a
result of the patients poor condition. The test
administrator read the statements out aloud,
sometimes rephrasing the item somewhat if the
patient was not able to understand. The test
administrator also assisted some of the patients
in marking yes or no on the form.
The psychiatrists in charge of the patients set the
diagnoses, using the DSM-IV criteria.
Data analyses

Based on ndings from previous investigations of

quality of life, four dierent factors were hypothesized to account for the variation in quality of
life: pathology, sense of self, personality, and
objective life circumstances. The pathology factor
comprised the GAF scores and the BPRS subscales
positive, negative, depressive, and general symptoms. Included in the tentative sense-of-self factor
were the variables mastery, LOC, sense of coherence, and self-esteem. The personality factor comprised only the TCI dimensions, and the objective
life circumstances were being employed, having

Determinants of quality of life

friends, living in ones own at/house, having
children, being married, and living with someone.
The analysis comprised two steps. First, in a
measurement part of the analysis, we constructed a
series of conrmatory factor models to investigate
the measurement model behind each of the independent factors. The main purpose was to nd out
if factors were homogeneous, e.g. if one, two, or
more subfactors best described the covariance
within each domain. Personality and objective life
circumstances were not included in these analyses.
The personality variables were already dened as
factors in the TCI instrument. The variables
included in objective life circumstances were all
kept, as it was suggested that they represented
separate phenomena. Instead, these variables were
regressed against subjective quality of life to sort
out the most important ones. In addition, the
dependent variables, the dierent domains of
subjective quality of life, were subjected to the
same kind of analysis. However, religion seemed to
be an irrelevant item for this population, with a
large proportion of missing data, and was therefore
excluded from further analyses.
The next step encompassed path-analyses to
explore the relation between all of the independent
and dependent variables extracted from the measurement part of our study.
The software used for the SEM was LISREL
8.50 (42). The STREAMS program (43) was used
as an aid to simplify the process of dening the
models and generating start values. The t between
data and a model was estimated by v2, by the t
index Root Mean Square Error of Approximation
(RMSEA), the Goodness-of-Fit Index (GFI), and
the Parsimony Normed Fit Index (PNFI). All are
well-known indexes and recommended in the
literature (35). The RMSEA estimates the lack of
t in a model compared to a perfect model; low
values indicate good t. The GFI estimates the
proportion of variance accounted for by the
estimated population covariance matrix and indicates good t when it is close to 1. The PNFI takes
into account the parsimony of the model and
should be as high as possible. In some cases we
compared models, and accordingly we use Dv2, i.e.
the difference in v2 between models. All presented
statistics were estimated with the maximum likelihood method.

Results
Step 1 the measurement part

The rst estimation made was to test whether the

dierent domains of subjective quality of life

formed a homogenous factor. A model with

one factor resulted in a rather good t (v2
41.22; df 20; P < 0.0035; RMSEA 0.099;
GFI 0.92), but all t indexes suggested that
more factors were possible. The modication
indexes suggested a high covariation between the
error terms for the two subscales work and nances
and we dened a new latent factor accounting for the
covaration. The new measurement model of subjective quality of life thus consisted of two factors. The
rst had positive loadings for leisure, living situation, safety, family relations, social relations, and
health, and the second had positive loadings for
work and nances (Table 1). The new model showed
a signicantly improved t compared with the onefactor model (Dv2 9.02; Ddf 1; P < 0.001;
GFI 0.93; RMSEA 0.080).
In total there were ve psychopathology variables, measuring depression, general, negative, and
positive symptoms, and GAF. First, an analysis
was made to test whether the pathology variables
formed a homogenous single factor or if there were
several subfactors. Conrmatory factor analysis
did not demonstrate good t for the one-factor
model (v2 31.28; df 5; P < 0.001), which
made us dene a second factor. The rst was
based on all variables and the second on GAF,
depression, and general pathology. The loadings in
Table 2 show that GAF had a negative loading to
the rst factor and a positive to the second. This
model with two pathology factors was found to
have a signicantly better t (v2 3.43; df 4;
P > 0.05; GFI 0.99), and therefore these two
pathology factors were kept for the path analyses.
Four variables were set to form the self-factor,
sense of coherence, mastery, LOC, and self-esteem.
A conrmatory factor analysis revealed good t for
the one-factor model (v2 2.52; df 2; P < 0.28;
GFI 0.99).
The variables included in objective life circumstances were regressed on the quality of life
factors, in a stepwise fashion based on their
signicant partial correlation. Three dichotomous
variables were selected on that criterion

Table 1. Loadings for the two quality of life factors

Quality of life dimension
Work
Leisure
Finances
Living situation
Safety
Family relations
Social relations
Health

Factor 1

Factor 2
0.52

0.77
0.65
0.67
0.49
0.55
0.58
0.74

137

Eklund et al.
Table 2. Loadings for the two psychopathology factors
Psychopathology variable
BPRS
BPRS
BPRS
BPRS
GAF

Psychopathology 1

Psychopathology 2

0.5
0.58
0.85
0.55
)0.82

0.49
0.49
0.48

negative
positive
general
depression

(P < 0.05), having or not having friends, living

in ones own at/house or not, and living with
someone or not.
With respect to personality, all variables with
signicant univariate correlation to one of the
quality of life variables were used (Table 3). Only
the variable reward dependence (not shown in
Table 3) was excluded on this criterion. Selfdirectedness had a high correlation to the rst
quality of life factor. Harm avoidance correlated
moderately and persistence and co-operation correlated weakly but signicantly to this variable. As
regards the second quality of life factor, novelty
seeking, self-transcendence and self-directedness
revealed signicant correlations.
In summary, the measurement part of our study
suggested that the following independent variables
(and factors) be included in our model: two
pathology factors, one factor of sense of self, six
personality variables, and three variables included
in objective life circumstances. Table 3 shows the
correlations between all variables.
Step 2 the path analyses

To create the factors in the measurement model,

variables with high loadings for each factor were
added together. This method, equivalent of setting
all loadings to 1, resulted in aggregated variables
having almost perfect correlation to factors based

on the estimated regression coecients from the

conrmatory analyses in step 1.
In a rst model tested, all independent variables
were rst dened as orthogonal and directly
contributing to the two factors of subjective quality
of life. In a preliminary analysis it was found that
some variables (co-operation and persistence) had
paths with coecients lower than 0.10, and these
paths were set to zero. In a second step, the
independent variables were set to be correlated.
Both these preliminary models were found to have
worse t compared to a model where correlation
was considered also between the dependent variables. The last model (model 1; see Fig. 1) had an
acceptable t to the underlying data structure
(v2 6.34; df 6; P < 0.39; RMSEA 0.023;
GFI 0.99; PNFI 0.09). The coecients from
model 1, presented in Fig. 1, were essentially the
same as the coecients in the rst preliminary
models tested.
Model 1 may, however, be too simple to account
for the theory behind quality of life in this group of
patients. We therefore tried a model that rested on
the principle that some variables inuence subjective quality of life indirectly through other variables
that serve as mediators of quality of life. Sense of
self and pathology were suggested as mediators,
while personality and objective life circumstances
were dened to be partly inuencing quality of life
through the mediators.
We started out with a tentative model with paths
from all external variables to all mediators and
dependent variables. Naturally, there were paths
between the mediators and the dependent variables
as well. A number of path coecients were very low,
so we trimmed the model by excluding all paths less
than 0.10. The result was a model (model 2a) with
rather poor t compared with model 1 (v2 190.28;
df 40; P < 0.00; RMSEA 0.186; GFI 0.80;

Table 3. Pearson correlations between all variables and factors included in the path analyses

Living with someone (A)

Living in own flat/house (B)
Having friends (C)
Novelty seeking (D)
Harm avoidance (E)
Persistence (F)
Self-directedness (G)
Co-operation (H)
Self-transcendence (I)
Self (J)
Psychopathology 1 (K)
Psychopathology 2 (L)
Quality of life 1 (M)
Quality of life 2 (N)

138

)0.30
)0.16
)0.04
0.02
0.12
0.10
)0.08
)0.01
0.15
)0.09
)0.10
0.15
0.10

)0.23
)0.15
)0.08
0.24
0.12
0.20
0.07
0.12
)0.39
)0.02
0.30
0.09

0.00
0.23
)0.31
)0.16
)0.18
)0.23
)0.21
0.27
0.03
)0.30
0.16

)0.23
)0.12
)0.08
)0.13
0.18
0.03
0.04
0.02
)0.14
)0.24

)0.25
)0.65
)0.17
)0.19
)0.70
0.51
0.30
)0.44
0.05

0.22
0.14
0.30
0.25
)0.34
)0.21
0.26
0.02

0.30
)0.06
0.82
)0.59
)0.26
0.67
0.20

0.19
0.19
)0.21
0.06
0.22
0.00

0.04
)0.11
)0.21
0.00
)0.22

)0.70
)0.39
0.76
0.16

0.47
)0.68
)0.17

)0.27
)0.21

0.30

Determinants of quality of life

Fig. 2. Model 2d with coefcients. Correlations, not shown in

the gure, were for QOL 1 and QOL 2 0.13, SELF and PATH
1 0.17, SELF and PATH 2 0.13, and PATH 1 and PATH 2
0.27.
Fig. 1. Model 1 with coefcients. LIVE, living with someone;
FL/HO, living in own at/house; FRIEND, having friends;
NS, novelty seeking; HA, harm avoidance; ST, self-transcendence; SD, self-directedness; SELF, the self-factor; PATH
1, pathology factor 1; PATH 2, pathology factor 2; QOL 1,
quality of life factor 1; QOL 2, quality of life factor 2.

PNFI 0.43). However, the parsimonious test

(PNFI) increased considerably. Further, freeing
the covariation (model 2b) among the personality
variables and the variables included in objective life
circumstances increased the t notably (v2 83.70;
df 34; P < 0.00; RMSEA 0.116; GFI 0.88;
PNFI 0.44). When the covariation between the
mediators was freed (model 2c), the t reached an
acceptable level (v2 38.82; df 31; P < 0.16;
RMSEA 0.041; GFI 0.95; PNFI 0.44). In
the last step, we freed the covariation between the
dependent variables (model 2d), which increased the
t signicantly (Dv2 7.12; Ddf 1; DP < 0.01;
v2 31.71; df 30; P < 0.38; RMSEA 0.0042;
GFI 0.96; PNFI 0.43). Coecients for the nal
model 2 are presented in Fig. 2.
Discussion

The selection of variables for inclusion in the

models was made on the basis of previous ndings
concerning variables of importance for subjective
quality of life, and we suggested four domains of
variables to be related to quality of life: objective
life circumstances, personality, self-factors, and
psychopathology. Our main results conrmed this

hypothetical model, indicating that all these factors

contributed to the explanation of subjective quality
of life.
Before any further conclusions can be made,
rst, the dimensionality of subjective quality of life
and, second, the dimensions among the determinants need to be discussed. The measure of
subjective quality of life used in the present study
investigates nine dierent life domains, eight of
which showed relevance for the present population
and were included in the analyses, and an overall
measure of quality of life comprising all life
domains included may be obtained. However, the
conrmatory factor analysis of the present study
demonstrated that this aggregation was suboptimal
in this sample and that a model with two factors
agreed better with the data. The rst quality of life
factor was composed of leisure, living situation,
safety, family relations, social relations, and health.
These variables seem to pertain to an inner
personal sphere, especially since another study on
a subsample of the same population showed that
leisure activities occurred almost exclusively in the
patients homes, and the social relations concerned
mostly professionals or family members (44). The
second factor comprised work and nances, thus
forming a more materialistic, external aspect of
quality of life. This result is similar to Meijer et al.
(45), who also arrived at a two-factor solution
based on the LQLKP. Still, it may be due to the
139

Eklund et al.
specic population used here, and the results must
be interpreted with this in mind.
The second question concerns whether the factors contributing to quality of life were onedimensional or multidimensional. Personality as a
concept has been dened as dimensions of dierences between people (39, 46), so even if there were
some correlations between the personality variables, for theoretical reasons we kept them apart in
our models. Besides, the correlations were very
week, except for harm avoidance and self-directedness, and this association will be further
discussed below. The dimensionality of psychopathology was somewhat problematic. All measures
of pathology were rather highly correlated, but it
was found that they formed two factors, one of
which correlated with all ve variables positive,
negative, depressive, and general symptoms
according to BPRS and global functioning as
measured by GAF. The direction of the associations was in an expected direction, as a high rating
on BPRS and a low rating on GAF indicate worse
psychopathology, and we viewed this as a main
factor, depicting general pathology. Concerning
the second psychopathology factor, however, the
associations between GAF and the other variables
(depressive and general symptoms), as well as
between GAF and the factor, were positive. Thus,
better functioning was associated with more
depressive symptoms. This pattern seems trustworthy for our population of patients with schizophrenia, but indicates that the ecological validity of
this study is limited to similar groups of patients.
We regarded this pathology factor as indicating
depression. The self-factor was homogeneous and
unproblematic, and all variables selected to measure this construct had high loadings on a single
factor. The variables included in objective life
circumstances were used as single variables, as they
represented separate phenomena. These were the
considerations behind our hypothetical model, and
the results must be interpreted against this background.
The rst model illustrated that there were a large
number of contributors to subjective quality of life.
This has been shown in previous research as well
(11, 12, 17). There was a fair amount of covariation
between the independent factors, making the
interpretation more dicult. For instance, the
self-factor was clearly the dominating determinant
of the rst quality of life factor, but other
determinants showed signicant relationships as
well. The psychopathology factors, e.g. were
important factors according to the correlations
(Table 3), but in the path analyses they were
overshadowed by the self-factor, and the coe140

cients were therefore comparably low. Among the

personality variables, self-directedness and harm
avoidance were signicant determinants. Both
these variables correlated to the self-factor and to
psychopathology. This correlational structure suggests that some of the determinants measured the
same underlying construct or that they were
causing each other. One possible way to solve the
problem of covariation amongst the determinants
was to dene some of them as mediators or
moderators of the prediction of the dependent
variable. In the present context two sets of variables were external to the mediating factors, personality and objective life circumstances. Models
2a2c depicted such a relationship between the
variables, where some inuenced mediators and
some inuenced subjective quality of life directly.
The t indexes RMSEA and PNFI revealed a
better t for these models as compared with the
simpler model without mediators (model 1).
According to both model 1 and model 2, the rst
quality of life factor, representing inner aspects,
was mainly determined by the self-factor, the rst
psychopathology factor, and the personality
dimensions harm avoidance and self-directedness.
As regards the second external factor of subjective
quality of life, the most important contributors
were the self-factor, having friends, and the
personality factor self-transcendence. It has been
shown in earlier studies that self-related factors
and personality are important for subjective quality of life (10, 1217). The relationship between
personality and self-related factors is a bit problematic to sort out, but personality has more often
been regarded as basic tendencies, determined
mainly by heredity (47) and early development
(32). The self, on the other hand, is composed by a
combination of basic personality variables, the
objective personal history, adaptation, and external situational inuences (47). In model 2 the selffactor was regarded as mediating quality of life,
depicting the fact that the self-factor is partly
inuenced by personality variables, but in addition
includes other aspects that are important in
predicting quality of life. Model 2 shows that
most of the common variance between self-directedness and quality of life, described in the shape of
correlations in Table 3, went through the mediating self-factor. The results also showed that selfdirectedness was the personality variable with
closest relationship to the self-factor, which is in
agreement with how the character traits are dened
in the model behind the TCI (39). The association
between harm avoidance and self-directedness is a
related issue, and such a relationship has been
reported in several studies (40, 48, 49), indicating

Determinants of quality of life

redundancy. Model 2 further indicates that the
personality variables self-transcendence and novelty seeking inuenced quality of life directly, while
self-directedness and harm avoidance worked both
through the mediators and directly. The conclusion
must be that personality and self, suggested in the
literature to be separate phenomena, on these
empirical grounds turned out to be only partly
separate. Self-directedness and harm avoidance
showed to be closely related to self, while the
remaining personality variables were not.
The positive associations of harm avoidance with
both quality of life factors seem puzzling, as the
opposite would be expected and the bivariate
correlations were negative or close to zero. However, the relationships depicted in Fig. 2 must be
viewed as dependent on each other, i.e. given the
other associations to the quality of life factors,
harm avoidance could explain an additional part of
the variation. For example, given the combination
of a high level on the self-factor, a high level of selfdirectedness, and living in ones own department/
house, a high level of harm avoidance could explain
additional parts of high ratings on the rst quality
of life factor. This is an example of how SEM
models can sometimes give rise to more complicated hypotheses based on how variables interact or
combine. More research is warranted before it is
possible to make a rm statement regarding harm
avoidance and quality of life in this group.
One crucial question for the trustworthiness of
this study is whether or not the model was correctly
specied as regards the variables included. One
variable that was not included was employment
situation, as very few were employed. One alternative would have been to focus on occupational
situation in a broader sense, including also, e.g.
activity centres, leisure activities, and household
work, which has been shown to be related to selfrated quality of life (15). Similarly, previous studies
have indicated that side-eects of antipsychotic
drugs (50), unmet needs (2), and cultural aspects
(4, 51) may be important predictors, and these were
not included in our model. However, the present
study focused on a broad combination of variables
of empirical and theoretical interest not previously
investigated in a multidimensional approach
personality, sense of self, psychopathology, and
objective life circumstances which adds new
perspectives on the important area of what determines self-rated quality of life for people with
severe mental illness.
A methodological shortcoming that may have
aected the results of this study is the selection
procedure, with one consecutively and one randomly selected sample. In addition, in the randomly

selected sample the most severely ill patients were

not asked to ll in the TCI. Despite this, the same
response rate was reached in sample 2 as in sample
1, where all patients were asked to participate, and
the samples did not dier in most important
characteristics, so the self de-selection in sample 1
seems similar to the extra selection principle in
sample 1. Another problem might be the fact that
the interviewers assisted some of the participants in
lling in the TCI. However, they were very careful
in not propelling any responses. Still, these limitations, together with the homogeneous and special
clientele studied, call for caution concerning generalization to other groups. Concerning sample size
in relation to number of variables, a minimum of
10 subjects per variable has been suggested (52).
Considering that there were two dependent factors
and 10 variables or factors in the present study, the
number of subjects was sucient, but at the lower
limit. To simultaneously estimate the measurement
model and the path analysis would have required a
larger sample, and consequently we refrained from
this.
Structural equation modelling including conrmatory factor analysis, as used in this study, has
been suggested as the most promising quantitative
approach for investigating factors of importance
for quality of life (3, 20). However, as proposed by
Katschnig (53), qualitative approaches seem to be
needed as well. The results of the present study,
that self and personality factors were the predominant determinants of quality of life, underscore
the need for in-depth qualitative methodology to
reveal phenomena that remain obscured in quantitative research.
In conclusion, quality of life of life proved to be
a complex phenomenon, best explained by several
determinants. The very strong relationship between
the self-factor and quality of life, as well as the high
correlation between personality variables and the
self-factor, indicated that trait-like factors formed
the most important source for determining both
quality of life factors. In addition, the psychopathology factors, which may be viewed as constituting a state-like condition, could explain a
substantial part of self-rated quality of life. Finally,
objective circumstances accounted for a minor part
of the variation in quality of life, especially the
more materialistic, external aspect of self-rated
quality of life.
Acknowledgements
We would like to thank Ulrika Bejerholm, Reg. O.T., and
Anita Bengtsson-Tops, Ph.D., for performing the data collection.

141

Eklund et al.
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