Illness Identity Research Articles

P495 The interplay of biopsychosocial factors and quality of life in Inflammatory Bowel Diseases: a network analysis

Abstract Background Quality of life (QoL) is one of the most relevant patient-reported outcomes in the treatment of patients with inflammatory bowel diseases (IBD), but does not only depend on disease activity. We aimed to investigate the interplay of biopsychosocial factors and their associations with QoL in patients IBD by using a network analytical approach (NA). Methods We measured QoL and anxiety, depression, illness identity, self-esteem, loneliness, childhood trauma, and visceral sensitivity with self-report questionnaires in two independent IBD-samples (sample 1: n=209, anonymous internet survey; sample 2: n=84, outpatients with active disease before the beginning of a biologic treatment). Additionally, fatigue, haemoglobin levels and response to biologic therapy (3–6 months after the first assessment) were assessed in sample 2. We estimated regularized partial correlation networks and conducted tests of accuracy and stability of the network parameters. Results In both samples, QoL had the strongest associations with visceral sensitivity and the illness identity dimension engulfment, a maladaptive integration of IBD into the ‘self’. QoL was uniquely associated with depressive symptoms and fatigue was an essential factor in this link (sample 2). Depression was the most central factor in the networks. Baseline depression scores were connected to response to biologic therapy in sample 2. Conclusion This is the first study using NA to assess the complex interplay between biopsychosocial factors and QoL in IBD. It reveals a comparable network structure in two independent samples emphasizing the importance of depression. Visceral sensitivity and engulfment connected most strongly to QoL. Beyond depression, visceral sensitivity and illness identity may be targetable characteristics to improve QoL in personalised holistic therapy in IBD.

The impact of illness identity on recovery from severe mental illness: A test of the model.

The Illness Identity model posits that self-stigma reduces hope and self-esteem among persons with severe mental illnesses, impacting a range of outcomes. The "insight paradox" anticipates that the negative effects of self-stigma are amplified by insight. This study tested these predictions using both cluster and path analyses. A total of 117 participants meeting the criteria for schizophrenia-spectrum disorders completed measures of self-stigma, self-esteem, hopelessness, insight, social functioning, coping, and symptoms. Cluster analysis supported the insight paradox; persons with low self-stigma/high insight had fewer psychiatric symptoms and better interpersonal functioning than persons with high self-stigma/low insight. Path analysis did not support the insight paradox, but indicated that self-stigma and insight impact different outcomes. Findings suggest that support for the predictions of the Illness Identity model and insight paradox are supported may depend on analytic method. Finding suggest that the benefits of self-stigma reduction may be constrained by insight.

Illness perceptions predict distress in patients with chronic kidney disease

BackgroundPatients diagnosed with chronic kidney disease (CKD) report increased distress associated with their clinical diagnosis. Distress in patients with predialysis CKD, has been linked to several adverse events; including increased risk of hospitalisation, early dialysis initiation and even death, suggesting that distress is a matter of great concern during routine care in predialysis CKD.AimsThe present study aimed to assess the nature of illness perceptions and the level of distress in a CKD cohort diagnosed with different stages of kidney disease. It also aimed to explore the correlates of distress and to create a model for distress and its associated predictors making use of hierarchical regression analysis.MethodsA sample of 200 patients diagnosed with Chronic Kidney Disease were recruited for this study from the nephrology outpatient clinics of Mater Dei Hospital, Malta. The participants were assessed for their; illness perceptions, treatment beliefs, level of depression and anxiety, coping style, as well as treatment adherence. Routine clinical information was also collected for participants, including a co-morbidity score.ResultsA percentage of 33.5% of the participants reported moderate distress, whilst 9.5% reported severe distress. Stronger illness identity, a perception of timeline as being increasingly chronic or cyclical in nature, greater consequences and higher emotional representations were associated with more advanced stages of CKD. In contrast, lower personal and treatment control and poorer illness coherence were associated with more advanced stages of CKD. Results from the hierarchical regression analysis showed that illness perceptions contributed significantly to distress over and above the clinical kidney factors. Being female, having low haemoglobin and specific illness perceptions including; perceptions of greater symptomatology, longer timeline, low personal control and strong emotional representations, as well as resorting to maladaptive coping, were all significantly associated with distress symptoms. Nevertheless, illness perceptions accounted for the greatest variance in distress thus indicating that the contribution of illness perceptions is greater than that made by the other known covariates.ConclusionIllness perceptions hold a principal role in explaining distress in CKD, relative to other traditional covariates. For this reason, illness perceptions should be addressed as a primary modifiable component in the development of distress in CKD.

Medication adherence in adult Chinese patients with asthma: role of illness perceptions and medication beliefs

Objective This study aimed to investigate the relationship between illness perceptions, medication beliefs, and self-reported adherence to inhaled corticosteroid (ICS) therapy in adult Chinese patients with asthma. Methods A cross-sectional survey was conducted in the asthma outpatient clinic of Zhongshan Hospital, Fudan University (Shanghai, China) between October 2018 and September 2019. Illness perceptions, medication beliefs, and medication adherence were assessed using validated scales, specifically the Medication Adherence Report Scale for Asthma, Beliefs about Medicines Questionnaire -Specific, and the Brief Illness Perception Questionnaire. Spearman correlation and multiple logistic regression were used to determine the relationship among these factors. Results: A total of 234 patients were included in this study. Of this group, 99 (42.3%) participants were non-adherent to their ICS medication. Medication adherence correlated negatively with ‘illness identity’ (perceived symptom), ‘emotional response’ (perceived emotional effect) and concerns about medication (r=-0.16, −0.16 and −0.15, respectively, p < 0.05). After adjusting for illness perceptions, medication beliefs and demographics, beliefs about the necessity of medication (odds ratio [OR]: 1.14, 95% confidence interval [CI]: 1.01–1.30), and emotional response to the disease (OR: 0.89, 95% CI: 0.80–0.99) were significantly associated with medication adherence in patients with asthma. Conclusion Beliefs about the necessity of medication and emotional response to the illness have a strong influence on self-reported medication adherence in adult patients with asthma in China. Interventions targeted adherence improvement among patients with asthma may be tailored to the individual’s baseline perceptions and medication beliefs, and focus on modifying inaccurate illness perceptions and medication beliefs as the main targets.

Illness identity and adjusting to type I diabetes: A four-wave longitudinal study.

Prior research has linked illness identity-or the extent to which the illness is integrated into one's identity-to diabetes-specific functioning. Four illness identity dimensions have been identified: rejection, acceptance, engulfment, and enrichment. As longitudinal research on this topic is scarce, this study examined developmental trajectories of illness identity and prospective associations between illness identity and diabetes-specific functioning. Adolescents and emerging adults with Type I diabetes, aged 14 to 25 (Mage = 19; 54% girls), participated in a four-wave longitudinal study spanning 3 years (N = 559 at Time 1). Participants filled out questionnaires on illness identity, treatment adherence, and diabetes-specific distress. Hemoglobin A1c (HbA1c) values were obtained from participants' medical records. To chart the development of illness identity over time, we performed latent growth curve modeling. Cross-lagged analysis was used to examine prospective associations between illness identity and diabetes-specific functioning. We observed small linear increases in acceptance (Mslope = .05, p < .01) and engulfment (Mslope = .03, p < .05) and a small linear decrease in rejection (Mslope = -.08, p < .001) across waves (with scale scores ranging between 1 and 5). Rejection negatively predicted and enrichment positively predicted treatment adherence 1 year later, which, in turn, positively predicted enrichment and negatively predicted engulfment over time. Furthermore, rejection and engulfment positively predicted diabetes-specific distress 1 year later. Finally, diabetes-specific distress and HbA1c positively predicted engulfment 1 year later. Standardized cross-lagged coefficients ranged between |.05| and |.11|. We identified small but interesting changes in three out of four illness identity dimensions. Prospective associations between illness identity and diabetes-specific functioning were bidirectional in nature. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychological Well-being in Adults with Congenital Heart Disease

Background: Due to advances in medical care and treatment of congenital heart disease (CHD), the number of adults with CHD (ACHD) is constantly growing. The psychological situation of ACHD has recently received increasing attention. There is evidence that adaptation to CHD may be affected by psychological factors, especially in how patients integrate their illness into their identities. The present study examined illness identity as a mediator of the association between a self-rated health and emotional distress among ACHD. Materials and Methods: The study used a cross-sectional design. A sample of 229 ACHD (38 ± 12.5 [18–73] years; 45% female) provided background data and completed three questionnaires on self-rated health (EuroQol group's visual analog scale), illness identity (Illness Identity Questionnaire), and emotional distress (Hospital Anxiety and Depression Scale) at the German Heart Center Munich. Serial multiple mediator models were tested using PROCESS macro for SPSS. Results: Perceived health had a direct and indirect effect on emotional distress which was mediated by illness identity (P &lt; 0.05). Compared to all other dimensions of illness identity, engulfment fully mediated the relationship between self-rated health and emotional distress, when adjusted for sociodemographic and clinical confounders. The model explained 42% of variance in total emotional distress (R2 = 0.416). The extent of emotional distress did not differ as a function of CHD complexity. Conclusions: Illness identity emerged as a strong mediating factor between a patient's self-rated health and psychological outcomes. More importance needs to be directed toward assessing a patient's health perception and psychological state, independently of cardiac severity. Based on present findings, targeted psychocardiological interventions should include psychoeducational components and emotion-focused strategies.

The effects of illness perceptions on their medication attitudes among patients with schizophrenia

IntroductionAntipsychotics are the primary treatment for patients with schizophrenia. However, medication non- adherence rate of schizophrenia patients is high. Illness perceptions have been identified as critical indicators to influence patients’ medication adherence and treatment process. Knowledge remains unclear about the effects of illness perceptions on medication attitudes among patients with schizophrenia.ObjectivesThis study aimed to investigate the effects of illness perceptions on medication attitudes among patients with schizophrenia.MethodsThis cross-sectional study was conducted in a regional teaching hospital in southern Taiwan with a convenience sample of 200 patients with schizophrenia recruited. Two self-reported scales, Illness Perception Questionnaire-Revised (IPQ - R) and Drug Attitude Index - 10 (DAI - 10), were used to assess patients’ illness perceptions and medication attitudes. Positive illness perceptions mean patients believe their illness acute, noncyclical, fewer consequences and emotional representation. And have more personal control, treatment control, and illness coherence.ResultsPatients’ illness perceptions were negative, with a little illness identity. Most of them believed that illness is more chronic and cyclical, causing negative consequences, lower self-control, and negative emotional expression. However, they thought treatment is moderately helpful for illness control, and the treatment effect is moderate. Multiple regression analysis showed that positive illness perceptions and negatively emotional representation could predict better medication attitudes.ConclusionsOur findings suggest that psychiatric mental health professionals could assess the illness perceptions of schizophrenia patients to influence their medication attitudes. Moreover, developing evidence-based interventions to improve their positive illness perceptions and decrease negative illness perceptions is needed.

Abstract P880: Assessing Measures of Patients Health Perceptions of Stroke Survivors as a Potential Tool for Health Care Disparities Research

Introduction: Patient centered research in stroke health care disparities is needed. Due to a call for the development of theory-based interventions for the reduction of stroke through behavior change, there have been new studies looking at the perception of an individual’s risk of stroke to create prevention models from those results. Leventhal’s Common Sense Model of Self-Regulation posits that individuals form beliefs about their illness and treatment that determines how they cope and their health behaviors in the future. The Illness Perceptions Questionnaire-Revised (IPQ-R) and Brief Illness Perceptions Questionnaire (BIPQ) are validated measures of these illness beliefs. Methods: A literature review was conducted with the following search criteria: (“illness perception” OR “illness belief”) AND (“stroke” OR “TIA” OR “transient ischemic attack” OR “cerebrovascular event” OR “cerebrovascular accident” OR “CVA”). MEDLINE, WorldCat, PubMed, George Smathers Library, and Google Scholar Database were searched. Systematic reviews and meta-analyses were excluded. Results: The initial results had 452 articles and 21 were chosen for data analysis. These articles were grouped into four categories: IPQ-R, IPQ-R &amp; Medication Adherence, BIPQ, and BIPQ &amp; Medication Adherence. Patients were most concerned about having another stroke and their symptoms becoming chronic. Medication beliefs are a stronger predictor of treatment adherence. Lastly, patients with stronger illness identity, causal beliefs, negative consequences, and lower coherence leads to greater distress in patients and caregivers. Conclusions: These results demonstrate that patients overall have concerns about their treatments, chronicity of stroke symptoms, and recurrence, and these concerns may not be effectively addressed during the routine clinic care demonstrated by effects on treatment adherence and patient and caregiver distress. Thus, patient perceptions questionnaires may be in particular a useful tool for health care disparities research in stroke.

Association of illness perception with chemotherapy-induced nausea and vomiting: a Turkish Oncology Group (TOG) study.

Chemotherapy-induced nausea and vomiting (CINV) may be linked to the psychological status of cancer patients. Therefore, the authors aimed to better understand the underlying risk factors for CINV using the Brief Illness Perception Questionnaire. A total of 238 patients were recruited during three cycles of chemotherapy. Patient, disease and treatment characteristics were noted at the onset of chemotherapy. The Brief Illness Perception Questionnaire was administered face-to-face prior to chemotherapy. The relationship between illness perceptions and CINV was analyzed using Spearman's rank correlation. Positive illness perception parameters, including personal and treatment control, were negatively correlated, whereas negative illness perception parameters, including consequences, timeline, identity, concern and emotions, were positively correlated with CINV after adjusting for age, sex and emetogenic potential of chemotherapy (p<0.001). Illness perception may be an underlying risk factor for CINV.

Illness Identity in Adolescents With Celiac Disease.

The aim was to examine the reliability and validity of the Illness Identity Questionnaire (IIQ) among adolescents with celiac disease (CD), to describe their illness identity characteristics, and to examine relationships between illness identity and self-reported participation in food-related activities and quality of life. Adolescents with CD (n = 91) were recruited for this cross-sectional study via social media interest groups. Participants completed online questionnaires: the IIQ, the CD Children's Activities Chart (CD-Chart), and the Pediatric Quality of Life Inventory (PedsQL). Internal reliability was established for IIQ items (α = 0.87) and for its 4 components (α = 0.75--0.90). The positive components (acceptance, enrichment) significantly differed from the negative components (rejection, engulfment), t(90) = 11.45, P < 0.001, d = 1.98. Feelings were more positive (M = 3.48, SD = 0.67) than negative (M = 2.06, SD = 0.76). The total IIQ was positively associated with the CD-Chart amount of activities (r = 0.30, P < 0.01) and enjoyment (r = 0.34, P < 0.001) and with the PedsQL social scale (r = 0.53, P < 0.001). The IIQ established acceptable reliability and validity. In all, the adolescents with CD exhibited an illness identity profile that was more positive and adaptive than negative. The IIQ can contribute to understanding the developmental status of illness identity during the critical transition process from adolescence to adulthood.

Illness Representations of Hypertension among Nepali Patients at a Tertiary Care Hospital Clinic: An exploratory survey.

The prevalence of stage 2 hypertension approaches one-third in adult Nepalis and despite inexpensive effective treatment, long-term compliance is poor. World-wide, a major impediment is the incongruity between hypertension and patients' symptom-based illness representations. The Common-Sense Model of Self-regulation was used to investigate Nepali illness representations through open-ended interviews of patients with hypertension. In a tertiary hospital setting, 50 self-identified hypertensive patients were interviewed about their representations of health, hypertension, and hypertensive treatment. Responses were analyzed with a modified Interpretative Phenomenological Analysis. An Ayurvedic-influenced health model appeared in illness identity and coping responses. Hypertension was identified as a serious disease having observable, wide-ranging symptoms with chronic and intermittent timelines. Concerns included side-effects and barriers to treatment. Further confirmation and investigation of Nepali common-sense hypertension models in a sample size sufficient for factor analysis is warranted for effective adherence interventions.

Perception of Illness and Its Association with Treatment Willingness in Patients with Newly Diagnosed Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease of immense public health relevance. Understanding illness perceptions in the NAFLD population will provide sound scientific evidence for planning high-quality patient-centered care and implementing effective interventions. The Brief Illness Perception Questionnaire (BIPQ) is a robust psychometric tool to systematically assess the dimensions of illness perceptions in various chronic ailments. In a cross-sectional study enrolling patients with newly diagnosed NAFLD, the sociodemographic, anthropometric, biochemical, and radiological determinants of enhanced illness perceptions (measured by the BIPQ score) were investigated using univariate and multivariable binary logistic regression analyses. Finally, the association between individual domains of the BIPQ and willingness to participate in comprehensive medical management was explored. In total, 264 patients (mean age 53 ± 11.9years, 59.8% males) were enrolled in the final analysis. The mean and median BIPQ scores in the study population were 30.3 ± 12.8 and 31.0 (IQR, 22.0-40.0), respectively. The variables having a significant independent association with heightened perceptions (BIPQ > 31) were family history of liver disease (aOR, 5.93; 95% CI, 1.42-24.74), obesity (aOR, 3.33; 95% CI, 1.57-7.05), diabetes mellitus (aOR, 2.35; 95% CI, 1.01-5.49), and transaminitis (aOR, 2.85; 95% CI, 1.42-5.69). Patients with a higher level of illness perceptions (31.6 ± 12.9 vs 27.8 ± 12.3, p = 0.022) were more likely to express a willingness to participate in the comprehensive management plan, with 3 of the 8 domains (consequence, identity, and treatment control) mainly affecting willingness. A family history of liver disease, obesity, diabetes, and transaminitis were independently associated with increased illness perceptions. A belief in serious consequences, a strong illness identity, and higher perceived treatment control were significantly associated with the willingness to undergo comprehensive care for NAFLD.

Illness identity on social media: a qualitative content analysis of #bpd.

To explore the themes related to self and illness representations in a public online community. This project utilised an inductive process of data analysis with a phenomenological approach. Two hundred images from the social media image-sharing platform Instagram were described, coded and organised into themes. Five themes were identified: the fragmented and obscured self; trepidation and disappointment about the threatening and persecutory world; an existence built of illness and symptoms; finding comfort in the natural and built environment; and sharing hope and positive experiences of growth. #bpd encompassed a variety of content types, with a wide spectrum of emotional tones expressed through photographs, written communication and artwork.

Stigma Resistance and Well-Being in the Context of the Mental Illness Identity.

We use a perceptual control model of identity to examine the relationship between stigmatized appraisals (from self and other) and well-being among individuals with serious mental illness. We also examine the role of stigma resistance strategies in the identity process. Using in-depth interviews with active clients of a community mental health center (N = 156), we find that deflection, or distancing oneself from mental illness, is associated with greater self-esteem and fewer depressive symptoms. Challenging others through education is associated with higher self-esteem, and challenging stigma through activism is associated with fewer depressive symptoms. Activism also moderates the relationship between identity discrepancy (the difference between appraisals from self and other) and well-being; however, the extent to which activism is helpful or harmful depends on whether appraisals from others are more or less stigmatizing than self-views. We discuss the implications of these findings for identity and stigma research.

Supplemental Material for Illness Identity and Adjusting to Type I Diabetes: A Four-Wave Longitudinal Study

Supplemental Material for Illness Identity and Adjusting to Type I Diabetes: A Four-Wave Longitudinal Study

Neurological and Psychological Determinants of Depression, Anxiety, and Life Quality.

Background:This study aimed to determine the major neurological and psychological elements affecting depression, anxiety (DEPXITY), and the overall quality of life.Methods:This analytical descriptive study was carried out on 141 respondents with formal mood disorder diagnosis, with mental illness identity, with current depression and anxiety symptoms of at least moderate severity and people with mild symptoms. Data were analyzed using descriptive statistics, correlation test, reliability test, and separate regression models. Statistical significant level was set as 0.05.Results:The findings showed that external control by others on one's own life (EC) is the most significant factor (0.45) related to depression and the social conflict (SC) was found to be the most influential factor (0.28) for the anxiety. Internal control over own personal life (IC) is the most significant factor to cure or regulate some of the negative symptoms of the anxiety (−0.66). Good performance in personal life (PP) is a common positive factor to regulate both depression (DEP) and anxiety (XITY). This study shows that DEPXITY is associated with negative life quality.Conclusions:The lack of internal control and the control by others on one's own personal life are associated with impaired cognitive, affective, and behavioral functioning. The results of this study can also be a good indicator and confirmation that the medial prefrontal cortex is able with the support of IC and PP to coordinate self-appraisal processes by regulating activity in the posterior cingulate cortex area of the brain.

Illness perceptions, coping, and health-related quality of life among individuals experiencing chronic Lyme disease.

The aim of the present study was to examine illness perceptions and coping in relation to the health-related quality of life (HRQOL) among individuals experiencing chronic Lyme disease (CLD). Participants were 82 individuals who had a confirmed diagnosis of Lyme disease and had been experiencing symptoms for 6 months or more. They were recruited through various online mechanisms (e.g., social media, online support groups), and they completed the consent form and questionnaires via Qualtrics. Participants completed questions about their demographics and health status as well as the Illness Perception Questionnaire-Revised (Moss-Morris et al., 2002), the Brief COPE (Carver, 1997), and the 36-item Short Form Health Survey (SF-36; Ware & Sherbourne, 1992). Illness perceptions and coping explained a significant amount of variance in HRQOL. Among the illness perceptions, the consequences and identity dimensions were most strongly associated with HRQOL. Behavioral disengagement and substance use were the coping strategies most strongly associated with the emotional health outcomes. Illness perceptions and coping are related to HRQOL among individuals with CLD. Given the increase in Lyme disease incidence and the chronicity of symptoms in some cases, it is critical to continue to examine the psychosocial factors associated with HRQOL in this population.

Fears for the future: A qualitative exploration of the experiences of individuals living with multiple sclerosis, and its impact upon the family from the perspective of the person with MS.

Notorious for its unpredictable nature, Multiple sclerosis (MS) can have a profound impact on all areas of a person's life, as well as the lives of their family. The aim of this qualitative study was to develop an in-depth understanding of the experiences of individuals living with MS and its impact upon the family system from the perspective of the person with M. Qualitative data were collected through semi-structured interviews conducted with 14 people living with MS (pwMS). Interviews lasted for approx. 1hr, were digitally recorded and transcribed verbatim. Anonymized data were then analysed using thematic analysis (Braun & Clarke, 2006, Qualitative Research in Psychology, 3, 77). The themes identified within participant narratives reflected the turbulent emotions experienced by pwMS after diagnosis and the impact upon their family. Three key themes were identified with six subthemes. The central themes were feeling let down by health care, fears for the future, and finding a way forward. Fears about loss of autonomy and independence characterized the narratives that notably focussed upon impact on the self, despite the study emphasis. Discussions of suicide also featured. The data demonstrate the psychosocial impact of living with MS as life-changing, encompassing traumatic losses and adaptation that was ongoing. The findings highlight the important role of health professionals and the dynamic impact of illness identity and engulfment. Opportunities to improve patient care by acknowledging the emotional impact of MS are discussed. Targeted and timely interventions to enhance psychological well-being, and areas for future research are considered.

Young Cancer on &lt;em&gt;Instagram&lt;/em&gt;

Young Cancer on &lt;em&gt;Instagram&lt;/em&gt;

The effect of illness perception on life quality in psoriasis patients

ABSTRACT Psoriasis is a chronic disease that has negative effects on quality of life. Understanding the illness perception of psoriasis is important for effective management of the disease and improving quality of life. The aim of this study was to determine the relationship between illness perception and quality of life in psoriasis patients. This cross-sectional study was performed with 306 patients who applied to a psoriasis outpatient clinic of a university hospital in Istanbul, Turkey. Data were collected using a sociodemographic characteristics and disease information form, the Dermatology Life Quality Index (DLQI), the Revised Illness Perception Questionnaire (IPQ-R) and the Psoriasis Area Severity Index (PASI) score. Data were analyzed using descriptive statistics, Kruskal-Wallis test and Mann-Whitney U test, Spearman correlation analysis, and multiple regression analysis. A positive relationship was found between scores on the DLQI and scores on the IPQ-R subscales of Illness identity, Consequences, Emotional representations, Time (cyclic), Personal attributions, External attributions, and Chance. A negative correlation was determined between DLQI scores and scores on the IPQ-R subscales of Treatment control and Illness coherence. Furthermore, there was a positive correlation between the PASI score and the DLQI scores and scores on the IPQ-R subscales of Consequences and Emotional representation. Multiple regression analysis showed that illness identity, PASI scores, treatment control, illness coherence, consequences, and personal attributions were significantly associated with quality of life (R2 = 0.365, p < 0.01). The quality of life of the psoriasis patients who associated their symptoms with the disease, who had a high PASI score, thought that they were adversely affected by the disease, and who saw personal attributions as the cause of the disease was negatively affected. The quality of life of patients who thought that their disease could be kept under control and who understood their disease was positively affected.