The importance of social comparisons for high levels of subjectivequality of life in chronic schizophrenic patients

Michael Franz, Thorsten Meyer, Tilman Reber & Bernd GallhoferCentre for Psychiatry, Justus Liebig University, Giessen, Germany

Accepted in revised form 17 July 2000

Abstract

In schizophrenic patients, quality of life (QoL) studies often ®nd high levels of general life satisfaction andsatisfaction in various life domains despite deprived living conditions. Therefore, the usefulness of QoL asan outcome indicator has been questioned. Since social comparison processes have been postulated to berelated to the level of satisfaction, this hypothesis was analysed empirically by the present study inschizophrenic patients. Satisfaction and social comparisons of 148 schizophrenic inpatients and 66 mentallyhealthy controls were examined with regard to the domains `health' and `family' by means of a standardisedinterview. The schizophrenic patients had a history of either long-term (n = 75) or short-term (n = 73)restricted and deprived living conditions. Long-term patients showed signi®cantly higher satisfaction levelsthan short-term patients. They compared themselves predominantly laterally or downwards with fellowinpatients. Signi®cant relationships between the direction of social comparisons and satisfaction ratingswere found in all three samples. Social comparisons proved to be important for the level of satisfaction inschizophrenic patients. Results indicate that experiences of restricted and deprived living conditions induceaccommodation processes and response-shifts that should be taken into account in the interpretation ofquality-of-life data.

Key words: Accommodation processes, Quality of life, Satisfaction, Schizophrenia, Social comparison

Introduction

In psychiatry, the term `quality of life' (QoL) hasbeen applied to objective living conditions, socialfunctioning, and the subjective experience of thepeople investigated, the latter consisting of an af-fective (well-being) and cognitive (satisfaction)component [1]. In psychiatric studies assessment ofthe subjective approach to QoL consists predom-inantly of ratings of satisfaction in various lifedomains relating to physical conditions, psycho-logical wellbeing, social contacts, and functioningin daily living [2±6]. However, a signi®cant pro-portion of research results is still di�cult tointerpret [7±9]. Although cross-sectional studieshave found mean satisfaction ratings to be lower inpsychiatric patients than in healthy persons, most

chronic patients nevertheless regard themselves assatis®ed despite de®cient living conditions [10, 11].The objective living situation is not re¯ecteddirectly and comprehensibly by subjective QoLassessments, as in psychiatric patients correlationsbetween standards of living and satisfaction invarious life domains were found to be low or zero,or they were even contrary to prior assumptions[2, 12, 13].

The role of internal comparison standards forthe regulation of satisfaction in schizophrenicpatients has been discussed [14, 15]. As early asthe 1950s studies indicated the important roleof referential cognition for the regulation ofsatisfaction [16]. Nevertheless, this approach hasyet to be applied to empirical research in psy-chiatry.

Quality of Life Research 9: 481±489, 2000.Ó 2000 Kluwer Academic Publishers. Printed in the Netherlands.

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Satisfaction and social comparisons

In social psychology, social comparisons are awidely acknowledged component of satisfaction-regulating processes [17]. In his theory of socialcomparisons, Festinger [18] postulated that peoplehave a need to compare their opinions and capa-bilities with other people in order to locate theirown position in life and in order to function ade-quately in society. Persons with whom we compareourselves are called objects of social comparisons.The direction of social comparisons determineswhether we compare ourselves with somebodywhom we regard as better, equal, or worse o� thanourselves. According to Wills [19], a person'ssubjective wellbeing can be increased by compari-son with someone perceived to be worse o�. It hasbeen found empirically that such `downward' so-cial comparisons occur mostly when a person ex-periences a physical or mental threat and thesituation appears to be unchangeable [20±22].Even comparison with somebody who is as badlyo� as oneself (`lateral' comparison) could to alesser extent increase subjective wellbeing by re-ducing a feeling of deviance [19]. Studies on de-prived social groups in the USA (ethnic minorities,employed women) showed the degree of experi-enced dissatisfaction to be closely related to socialcomparisons [23, 24].

It has been reported that internal standards ofcomparison on which a person bases his or herperception are subject to change over time [25]. Itwas postulated that this shift of internal standardsshould lead to a response-shift in quality of lifeassessments [25].

Objectives

The present study examined the role of socialcomparison processes in QoL-judgements of psy-chiatric patients. Only schizophrenic patients wereincluded in the study in order to reduce con-founding of results by psychiatric diagnosis.Therefore, it focuses on a patient group of out-standing public health relevance with regard toprovision of long-term services, for which uncriti-cal interpretation of high levels of QoL in terms ofsatisfaction ratings could lead to wrong planningdecisions.

The following hypotheses were tested:

(1) Satisfaction in speci®c life domains is higher inthe long-term than in the short-term hospitalisedpatients (see [8, 9]).(2) Long-term hospitalised patients di�er from theshort-term patients in terms of objects of socialcomparison. It is expected that they comparethemselves predominantly with their fellow inpa-tients (`intra-group comparison').(3) Comparisons with fellow inpatients made bythe long-term hospitalised patients are lateral ordownward in direction, i.e. they are made withpersons whose objective living situation is per-ceived as equal or worse. Comparisons by short-term hospitalised patients would be expected to berelatively more upward in direction.(4) Upward social comparisons are related to alower subjective quality of life, downward socialcomparisons to a higher subjective quality of life interms of satisfaction ratings.

Methods

Samples

In order to investigate social comparisons inschizophrenic patients with regard to accommo-dation and quality of life, `duration of hospitalstay' served as a criterion to distinguish two dif-ferent patient groups (Table 1). Mentally healthypersons served as a control group.

Schizophrenic patients with long-term durationof present hospitalisation (LP)All patients of ®ve psychiatric hospitals with long-term wards who had been hospitalised for a con-tinuous period of at least 2 years and who satis®edthe diagnostic criteria of schizophrenia as perICD-10 (F20.0, F20.1, F20.5) were included. Ofthe resulting 132 patients, 57 were unable or re-fused to participate, whereas 75 completed theinterview.

Schizophrenic patients with short-term durationof present hospitalisation (SP)This sample was gathered from ®ve di�erent wardsof two psychiatric hospitals. Their duration ofpresent stay had to be less than 3 months and theyhad to su�er from schizophrenia as per ICD-10(F20.0±F20.3). Of the resulting 105 patients,

482

32 refused or discontinued the interview, whereas73 completed the interview.

In both samples of schizophrenic patients de-mentia and mental retardation served as exclusioncriteria.

Mentally healthy controls (HC)Mentally healthy controls were consecutively re-cruited from the patients of a general practitioner(n = 70). These persons decided anonymouslywhether they would ®ll out a standardised ques-tionnaire. Therefore, information on their refusalrate were not available.

Measuring instruments

Subjective QoL and social comparisons were as-sessed by means of a standardised interview. In apreceding study, three life domains had beenidenti®ed to be central for the subjective QoL inthis patient group [26]. They were selected as

domains of analysis in this study: `friendship',`health', and `family'. As both `friendship' and`family' represent social relationships and similarresults emerged for both domains, only the resultsof the `family' and the `health'-domain are pre-sented.

Subjective QoLSatisfaction ratings served as indicators of sub-jective QoL in accordance with prominent QoLinstruments (e.g. Quality of Life Interview [27],Lancashire Quality of Life Pro®le [7]). As in thesescales, patients rated their degree of satisfactionwithin the selected life domain on a seven-pointrating scale (1 = very dissatis®ed to 7 = verysatis®ed).

Social comparisonsIn social psychology object and direction of socialcomparisons are assessed either explicitly (e.g. ``Isyour health better, worse, or equal to [name of

Table 1. Sociodemographics of long-term (LP) and short-term (SP) schizophrenic inpatients and mentally healthy controls (HC)

LP (n = 75) SP (n = 73) Di�erence LP±SP (t-test, v2-test) HC (n = 70)

Age (in years) 60.0 (�12.5) 36.3 (�11.5) p < 0.001

t = 12.0; df = 146

36.9 (�23.1)

Sex 34f/41m 28f/45m NS

v2 = 0.74; df = 1

52f/18m

Marital status

Single 66 50 p < 0.01 25

Married/partnership 1 13 v2 = 12.75; df = 3 34

Divorced 6 8 7

Widowed 2 2 4

Education

None 8 3 p < 0.001 3

Special school 6 1 v2 = 25.14; df = 4 0

Intermediate 43 22 15

Technical high school 10 13 19

University entrance quali®cation 6 26 32

Duration of illness 36.1 (�11.1) 8.3 (�7.3) p < 0.001

t = 17.6; df = 139

Number of psychiatric admissions 5.2 (�6.0) 6.3 (�6.6) NS

t = )1.0; df = 144

Years of present hospitalisation 25.4 (�14.3) 0.1 (�0.01) p < 0.001

U = 0.00; Z = )10.4*

Cumulative duration of

hospitalisation (years)

31.5 (�12.8) 1.2 (�1.8) p < 0.001

t = 19.3; df = 136

*Mann±Whitney U-test due to unequal variances.

NS = Not signi®cant.

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another signi®cant person, speci®ed by intervie-wee]'s health'') or implicitly by means of analysisof open-ended questions [28]. As none of thestrategies has been shown to be superior, it hasbeen suggested that di�erent assessment strategiesshould be applied [28]. Therefore, the presentstudy assessed the object and direction of socialcomparisons of schizophrenic patients by means ofboth open- and closed-ended standardised ques-tions. All interviews were conducted by a singleinterviewer (T.R.).

The patients were ®rstly asked how theyevaluated the health/family situation of others(``How is the health/family situation of otherpeople?''). After the interview, the answers of thepatients were transcribed and coded indepen-dently by two raters (T.M. and T.R.) in terms ofthe persons mentioned spontaneously (object ofsocial comparisons; cf. Figure 2) and the pa-tients' appraisal of the situation as better, equal,or worse (direction of social comparisons; cf.Figure 3). Objects of comparison were coded aseither fellow inpatients, friends and acquain-tances outside the psychiatric institution, familymembers, people in general, or others. Interraterreliability was jobject = 0.98 and jdirection =0.93. Within this study this approach is referredto as implicit questioning on the objects anddirection of social comparisons.

In addition, people compared themselvesexplicitly with their fellow inpatients, indicatingwhether they considered them to be better o�,equal, or worse o�. In order to test the validity ofthis approach, mentally healthy controls (HC, seeTable 1) were likewise asked questions on socialcomparisons and satisfaction with regard to healthand family. To this end, consecutive patients of ageneral practitioner were asked to complete astandardised questionnaire anonymously.

Analysis

Nonparametric statistics and tests were applied,because no more than ordinal scale level couldbe assumed. Di�erences of satisfaction ratingsbetween the three samples were analysed by meansof paired Mann±Whitney U-tests. The adjustmentfor the type 1 error rate in three comparisons(Bonferroni procedure, a = 0.05) resulted inai = 0.017. This should be taken into account in

the interpretation of the comparisons. Relation-ships between satisfaction ratings and direction ofsocial comparisons were analysed by Spearman'srank coe�cient rs. The v2-test was used to analysedi�erences of frequencies with regard to the an-swers on objects and direction of social compari-sons (implicit question).

Results

Did long-stay and short-stay inpatients di�erin terms of satisfaction?

Both life domains showed signi®cantly highersatisfaction levels in long-stay inpatients as com-pared with short-stay inpatients and even ascompared with healthy controls (Figure 1).

Did long-stay and short-stay inpatients di�erin terms of objects of social comparison?

When asked how they view the health/familysituation of others, two-thirds of the long-stayinpatients talked about a fellow inpatient, whereasfewer than a third of short-stay inpatients men-tioned a fellow inpatient with regard to health andonly 9% did so with regard to family situation

Figure 1. Satisfaction (median, 25% and 75% percentile,

mean) in the domains `health' and `family': di�erences (Mann±

Whitney U-test) between schizophrenic long- and short-term

inpatients and mentally healthy controls. ***p < 0.001;

**p < 0.01; n.s. = not signi®cant.

484

(Figure 2). The corresponding di�erences betweenlong-stay and short-stay inpatients were signi®cant(v2health � 11:3; df = 1; p < 0.001, v2family � 25:8;df = 1; p < 0.001).

Interestingly, short-stay inpatients most oftendid not refer to a real, identi®able person, butcompared themselves with `everybody', `manyother people', or `people in general'. Withinthe health domain comparisons were made withreference persons outside the hospital (family andfriends) just as comparisons with fellow inpatients.If the `people in general' were regarded as people`outside', too, 72% of the comparisons were madewith people outside the hospital setting, even 92%with regard to the `family domain' (Figure 2).

Did the direction of social comparisons di�erbetween long-stay and short-stay inpatients?

Social comparisons made by long-stay inpatientswere directed mostly laterally or downwards withregard to the implicit question (Figure 3). Amongthe short-stay inpatients, more upward compari-sons and fewer lateral and downward comparisons

were found on a descriptive basis, however thisdi�erence was signi®cant only with regard to the`family'-domain (v2family � 9:9; df = 2; p < 0.001),a ®nding which could be explained primarily bythe high proportion of lateral comparisons in long-stay inpatients (70%). Signi®cant or descriptivedi�erences were not found with regard to theexplicit comparison with a fellow inpatient. Inboth groups about four out of ®ve comparisonswere rated by the patients as downward or lateral(health: long-stay inpatients: 47% lateral, 33%downward; short-stay inpatients: 35% lateral,45% downward; family: long-stay inpatients: 46%lateral, 32% downward; short-stay inpatients:45% lateral, 37% downward). This was similar tothe answers of the healthy controls (health: 41%lateral, 33% downward; family: 40% lateral, 40%downward).

Was there a relationship between directionof social comparison and subjective QoL?

A signi®cant relationship of this kind was dem-onstrated for the mentally healthy controls: adownward direction of social comparison was as-sociated with increased subjective QoL (Table 2).

Figure 2. Patients' objects of social comparison in long- and

short-term inpatients for the domains `health' and `family'.

(Proportion of answers to the implicit question ``How is the

health/family situation of other people?'').

Figure 3. Direction of social comparisons (upward, lateral,

downward) in long- and short-term inpatients for the domains

`health' and `family'. (Proportion of answers to the implicit

question ``How is the health/family situation of other people?'').

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For the short-stay inpatients also, the direction ofsocial comparisons correlated signi®cantly andnegatively with satisfaction ratings in both lifedomains (Table 2).

In the long-stay inpatients the postulated signif-icant correlation was found for both methodolog-ical approaches with regard to health. With regardto the family domain the answers to the explicitquestion on direction of social comparison corre-lated signi®cantly and negatively with satisfactionratings. Although the answer to the implicit ques-tion was also found to correlate in the expecteddirection, it did not reach the signi®cance level.

Discussion

A number of studies have shown the importance ofsocial comparisons in relation to subjective qualityof life in physically ill patients (e.g. [20, 28]).However, no such empirical study had been con-ducted with psychiatric patients. The present studyfound clear empirical evidence that social com-parisons must be regarded as an important factorin¯uencing the level of subjective QoL and satis-faction in schizophrenic patients.

(1) It was con®rmed that schizophrenic patientswho lived under hospitalised conditions for a longtime are signi®cantly more satis®ed with importantlife domains (health and family situation inthe present study) than patients who have beenhospitalised for less than 3 months and expect toleave this setting in the near future. It must be

remembered, however, that the objective livingsituation of long-stay inpatients in terms of mentaland physical health, family life, and social networkcan be regarded as considerably worse than that ofshort-stay inpatients [13]. The same should holdtrue for patients in long-term hostels in commu-nity care.

(2) Signi®cant negative relationships werefound between level of satisfaction and directionof social comparisons. This corresponds to theo-retical assumptions and empirical results in men-tally healthy people [19], in whom lateral anddownward comparisons were found to be relatedto an increased level of satisfaction.

(3) It is known from the literature that intra-group comparisons are made by people who ex-perience a deprived living situation they view asunchangeable [20±22]. In this study a high level ofintra-group comparison was found in the (verysatis®ed) long-stay schizophrenic inpatients. The(more dissatis®ed) short-stay inpatients comparedthemselves more often with people outside thehospital (family and friends). Often they refer to`people in general', which might indicate that theirframe of reference for `normality' is located inhealthy others. This supports Lally's ®ndings [29]regarding the development of an `illness identity'in chronic schizophrenic people, namely that in theinitial phase patients try to preserve an identitythat is as normal and healthy as possible, while in asubsequent phase they have a sense of a parallel,normal, non-mentally-ill life going on and feel thatthey just need to get back on track [29].

Table 2. Correlation between direction of social comparison and satisfaction (Spearman's rank coe�cient and number of valid

responses)

Satisfaction

Schizophrenic patients with

long-term hospitalisation

Schizophrenic patients with

short-term hospitalisation

Mentally healthy patients

from general practitioner

Health Family Health Family Health Family

Direction of

social

comparison

Implicitly

assesseda)0.30* (28) )0.28 (21) )0.35** (49) )0.44** (34) NA NA

Explicit comparison

with fellow inpatientb)0.35** (57) )0.37** (59) )0.31** (69) )0.26* (57) )0.29** (66) )0.53*** (66)

aHow is the family/health situation of other people?b Comparing your situation with those of your fellow inpatients, do you feel you are better o�, the same, or worse o�?

* p < 0.05; ** p < 0.01; *** p < 0.001.

NA = Not available.

486

(4) It has been postulated that the primary di-rection of comparison among people su�eringchronic, unchangeable deprivation is lateral ordownward [16]. The present study con®rms thishypothesis in chronic schizophrenic patients.Short-stay inpatients do not characterise their sit-uation as long-term and unchangeable [29]. Thisgroup of patients made more upward social com-parisons with people outside the hospital (familyand friends).

(5) Di�erences in objects and direction of socialcomparisons between short-term and long-termhospitalised patients suggest underlying accom-modation processes. A signi®cant positive rela-tionship between satisfaction in various lifedomains and duration of hospitalisation in long-term psychiatric care has been reported [13]. Thus,the accommodation of satisfaction in long-stayinpatients could be mediated by the changes ofinternal referents such as social comparisons.

As expected, social comparisons cannot accountfor the entire variance in subjective QoL. In ad-dition to social comparisons, there must be otherinternal and external standards of comparisonthat serve as references in the evaluation of thepatients' own situation. Suls [30] showed thattemporal comparisons, i.e. intra-individual com-parisons with former life situations, become moreimportant with increasing age. Fillip et al. [31]found that in old people temporal comparisonsdominate over social comparisons. Similar resultswere reported by A�eck and Tennen [28], whofound more temporal than social comparisons inpatients su�ering from arthritis. Di�erencesbetween long-stay and short-stay inpatients interms of the comparisons they make might be dueto a di�erence in age, this di�erence being morethan 20 years on average in the present study.Future studies should analyse the signi®cance ofother internal frames of reference (e.g. aspirationlevel, temporal comparisons) for the satisfactionratings of schizophrenic patients. In addition, thispatient group in particular may have `imaginedobjects of comparison' due to psychopathology(cf. [32]) that are scarcely accessible to presentassessment methods. Moreover, high levels ofsatisfaction in the long-stay inpatient group mightalso be considered as a process of selection: therecould be a higher motivation to discharge a dis-satis®ed patient compared to a content person

from a long-term care facility. Furthermore, anobvious reason as to why short-stay inpatients areless likely to use other patients for comparison isthat they have had less time to get to know them.By the same token, long-stay inpatients have lessexperience with persons that would allow upwardcomparisons. However, objects and direction ofsocial comparisons may not only be explained byexistent contact numbers and experiences. Forexample, the short-term patients often referred to`people in general', which appears to be a meta-phor for `normal life'. Since signi®cant negativecorrelations between direction of social compari-son and satisfaction were found in all patientgroups, speci®c characteristics of the groups arenot likely to explain the present results.

High refusal rates ± of 43.2% in the long-termand 30.5% in the short-term patients in the presentstudy ± are not uncommon to self-report data inpatients with a high level of disability such aschronic schizophrenic patients. Due to data pro-tection policies, no data is available to analysedi�erences between participants and non-partici-pants. Experiences in other studies with chronicschizophrenic patients suggest that either patientswith pronounced positive symptoms (e.g. delu-sions, hallucinations), negative symptoms (e.g.emotional withdrawal), poor compliance or severecognitive de®cits could not be included in thisstudy. Therefore, more severely disturbed patientsmight not be represented in the data.

In both schizophrenic patient groups more lat-eral than downward comparisons were found. Thiscould re¯ect `social desirability' (downward com-parisons as a socially undesirable response [31]).On the other hand, there is evidence that lateralcomparisons are made if downward comparisonsare just not possible any more [33], which could betrue of the long-stay inpatients. Social desirabilityshould be controlled for in future studies. Due torestrictions with regard to the length of interviews,only three life domains of the patients were anal-ysed. The selected domains could have been proneto intra-group comparisons. Nevertheless, short-stay inpatients did compare themselves more oftenwith people `outside', and compared to other lifedomains the selected ones were of central impor-tance to the quality of life of schizophrenicpatients [26]. This is the ®rst study to addressthis topic on an empirical basis in schizophrenic

487

patients. Therefore, the ®ndings have to be repli-cated and inferences about validity of satisfactionratings in schizophrenic patients should be madewith caution.

The results of the present study support the as-sumption that referential frames such as socialcomparisons are subject to accommodationprocesses that could lead to a response-shift in theassessments of QoL in schizophrenic patients.Where subjective QoL assessment in terms of sat-isfaction ratings is used as a criterion for theevaluation of treatment e�orts, unexpectedly highlevels of subjective QoL should not lead to wrongplanning decisions or non-provision of neededservices [7]. Satisfaction ratings should not serveas an exclusive empirical justi®cation for discon-tinuation of rehabilitative programs (e.g. deinsti-tutionalisation [13]). The present indications oflong-term accommodation processes should betaken into account in the interpretation of sub-jective QoL data and should serve as a stimulus tofurther basic research.

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Address for correspondence: Dr M. Franz, Centre for Psychia-

try, Justus Liebig University, Am Steg 24, 35385 Giessen,

Germany

Phone: +49-641-99-45755; Fax: +49-641-99-45769

E-mail: michael.franz@psychiat.med.uni-giessen.de

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