Skip to main content
The Egyptian Journal of Bronchology
Download PDF

Assessment of sleep quality, anxiety, depression, and quality of life in Behçet’s disease

The Egyptian Journal of Bronchology volume 17, Article number: 26 (2023) Cite this article

Abstract

Background

Behçet’s disease (BD) is a multi-organ disease with different systemic manifestations. While rare in the United States and Europe, it is more common in the Middle East and Asia. BD is one of the commonest encountered vasculitis in Egypt. This study aims to evaluate BD patients' sleep patterns, quality of life, and psychological aspects.

Methods

Patients suffering from Behçet’s disease (thirty patients) and 30 matched age and sex-healthy control participants were recruited in our study. The assessment included the entire clinical history and laboratory investigations, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and Oxygen saturation level. Evaluation of sleep quality and presence of sleep-disordered breathing was done using the Pittsburgh Sleep Quality Index (PSQI), Insomnia severity index (ISI), and Epworth sleepiness scale (ESS). Hamilton’s anxiety (HAM-A) and depression rating scales (HAM-D) were used for psychological assessment. The Short Form 36 Quality Of Life Scale (SF-36 QOL) assessed participants' quality of life.

Results

Behçet’s disease patients suffered significantly higher levels of anxiety and depression compared to the control group. The prevalence of insomnia and daytime sleepiness was significantly higher among BD patients. All components of PSQI, including the global score, were significantly higher among the BD group. Physical functioning, role limitation due to physical health, and emotional problems; also, general health indices were significantly lower for the BD group. Patients with active BD showed significantly higher levels of anxiety, depression, insomnia, day time dysfunction and significantly lower all domains of the SF-36 QOL Scale.

Conclusions

BD is associated with low sleep quality and high levels of anxiety and depression.

Disease activity directly impacts anxiety, depression levels, lower sleep quality, and lower quality of life among BD patients.

Trial registration

ClinicalTrials.gov. NCT05142995. Registered November 20, 2021.

Background

Behçet’s disease (BD) is a multisystem, autoimmune disease representing a form of systemic vasculitis. The clinical picture associated with BD is diverse and complex, including various symptoms affecting almost all body systems [1]. These diverse manifestations proceed in a cycle of remissions and exacerbations, reframing quality of life (QOL) in those patients and representing a massive concern for them and their families.

Sleep quality is an essential component of QOL. Sleep disturbance is described in the literature in relation to various rheumatic diseases, including BD [2,3,4]. Neurological involvement in BD is variable, which ranges between 2–50% among studies [5, 6]. Even without neurological involvement, neuropsychiatric symptoms, including anxiety and depression, are commonly described in BD. An incidence of 86% of psychiatric illness was reported after the first manifestations of the disease [7].

Several aspects impact sleep quality in BD patients, including disease duration, disease activity, treatment, and psychological disorders. All these factors affect QOL in BD patients.

This study aims to; evaluate sleep quality and efficiency, psychological aspects, and the impact of such factors on health status and quality of life for BD patients and their relation to disease activity.

Patients and methods

Study participants and ethical approval this prospective case–control study was performed on 30 BD patients in the age group of 18–60 years diagnosed via International Criteria for Behçet’s disease; point score system: scoring ⩾4 indicates Behçet’s disease [8] and 30 healthy matched control participants. Patients were recruited from outpatient clinics and wards of physical medicine, rheumatology, rehabilitation department, and Assiut university hospitals from October 2021 to October 2022.

Informed written consent was obtained from participants. Exclusion criteria were evidence of end-organ failures such as heart failure, a liver cell or renal failure, history of psychological disturbance or medications, and inability to obtain written informed consent. The Faculty of Medicine, Assiut University's ethical committee approved the study protocol under the Declaration of Helsinki.

Demographic, clinical, and laboratory data history taking, full clinical examination, and comorbidities such as Diabetes, Hypertension, and BD medication were assessed. ESR, CRP, and oxygen saturation level (SpO2) were obtained for all participants.

Behçet’s disease assessment

Behçet's Disease Current Activity Form (BDCAF)

Patients were further categorized according to disease activity into active BD group and inactive BD group according to BDCAF. BDCAF is a tool to assess disease activity through data in the last four weeks before recruitment on a scale from 0 to 12, with scores > 4 considered an active disease [9].

Krause’s Behçet’s disease activity assessment

Total clinical severity score for BD was calculated as the sum of 1 point for each of the mild symptoms (Mouth ulcers, Genital ulcers, Skin lesions, Arthralgia, Recurrent headaches, Epididymitis, Mild gastrointestinal symptoms, Pleuritic pain, Superficial vein thrombosis), 2 points for each of the moderate symptoms (Arthritis, Deep vein thrombosis of the leg, Anterior uveitis and Gastrointestinal bleeding) and 3 points for each of the severe disease manifestations (Posterior/pan uveitis, retinal vasculitis, Arterial thrombosis or aneurysm, Neuro-Behçet and Intestinal perforation) [10].

Vasculitis damage index (VDI)

The VDI is comprised of 64 items of damage (grouped into 11 organ-based systems) defined by a consensus of experts to represent forms of damage in patients with systemic vasculitis. Behçet’s disease is considered a systemic vascular disease. We aimed to study the relationship between VDI and the psychological impact on BD, sleep quality, and QOL [11, 12].

Assessment of anxiety and depression

Hamilton Anxiety Rating Scale (HAM-A)

Consists of 14 items and measures both psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety). Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where a score ≤ 17 indicates mild anxiety, 18–24 mild to moderate severity, and more than 24 moderate to severe anxiety [13].

Hamilton Depression Rating Scale (HAM-D)

The original HAM-D has 21 items, but scoring is based only on the first 17. Scores less than or equal to 7 indicates normal response, 8–13 mild depression, 14–18 Moderate, 19–22 severe, and more than 22 very severe depression [14, 15].

Assessment of sleep quality

Insomnia severity index (ISI)

The version intended to be completed by a clinician for subjective assessment of the patient’s symptoms and consequences of insomnia. ISI contains seven domains assessing sleep-onset difficulties, sleep maintenance, sleep satisfaction, effect on daily functioning, impairment attributed to sleep problems, and distress associated with insomnia. Each item is rated on a 0–4 scale, and the total score ranges from 0 to 28. A higher score suggests more severe insomnia [16, 17].

Epworth sleepiness scale (ESS)

Self-administered questionnaire assessing the likelihood of daytime sleepiness. Subjects describe how often they fall asleep or doze in specific situations on a scale of 0–3, with total scores ranging from 0 to 24. An ESS score ≥ 10 is indicative of subjective excessive daytime sleepiness. [18, 19].

Pittsburgh Sleep Quality Index (PSQI)

Self-reported questionnaire consists of a combination of Likert-type and open-ended questions to indicate how frequently participants experienced sleep difficulties over the past month. Scores for each question range from 0 to 3, with higher scores indicating more acute sleep disturbances. Consisting of 19 items, the PSQI measures several aspects of sleep, offering seven component scores and one composite score. The global PSQI score is then calculated by totaling the seven component scores, providing an overall score ranging from 0 to 21 [20, 21].

Assessment of Health status and QoL

SF-36 QOL Scale was used to assess the quality of life among participants. SF-36 includes eight domains; physical functioning, social functioning, role limitations due to physical impairment, role limitations due to emotional problems, mental health, vitality, pain, and general health. The scale was assessed regarding the last four weeks. Scores of each category ranged from 0 to 100, where 0 represented the lowest QOL and 100 the highest QOL [22, 23].

Statistical analysis

SPSS program (version 20, IBM and Armonk, New York) used for data management. Mann–Whitney test was used for continuous data while Chi2-test compared nominal data. Different correlations of continuous variables in the study were assessed with spearman’s correlation. The sample size was estimated by Open Epi V.3.01 computer program.

Results

In the current study, 80% of BD patients were males with a mean age of 34.7 ± 8.8. Demographic and baseline data for the BD and control groups showed no significant difference (Table 1). The BD group had significantly higher ESR and CRP compared to the control with significantly lower SpO2 readings. Anxiety and depression levels; were significantly higher among BD patients than in the control group (Table 2).

Table 1 Demographic data of Behçet’s Disease patients and control group (n = 60)
Full size table
Table 2 Laboratory data, HAM-A, HAM-D, ISI, and ESS of Behçet’s Disease patients and control group (n = 60)
Full size table

The BD group was associated with high level of sleep disturbance, including a high level of insomnia (p < 0.001) and daytime sleepiness (p < 0.001) compared to the control group (Table 2). All domains of PSQI were significantly higher for the BD group, with PSQI global score significantly higher compared to the control group (9.17 ± 4.31 vs. 1.77 ± 1.97; p < 0.001) (Table 3).

Table 3 Pittsburgh Sleep Quality Index for Behçet’s Disease patients and control group (n = 60)
Full size table

Patients with BD showed lower values regarding health status and QOL versus control with significantly lower values for physical functioning, Role-physical, Role-emotional, and general health (p = 0.007, p = 0.008, p = 0.03, and p = 0.004; respectively) (Table 4).

Table 4 Health status and quality of life assessment for Behçet’s Disease patients and control group (n = 60)
Full size table

Regarding clinical characteristics, active BD patients showed insignificant differences regarding age and gender (Table 5), with a significantly higher frequency of fever, fatigue, skin lesions, and pulmonary manifestations than the inactive group. Disease duration was longer among active BD (8.34 ± 5.1 vs. 5.85 ± 2.73; p = 0.029) than the inactive group. All disease assessment scales were significantly higher among active BD patients, including BDCAF score, Krause’s severity score, and VDI (p < 0.001, p < 0.001, and p = 0.002, respectively) (Table 6).

Table 5 Demographic data of Behçet’s Disease patients according to disease activity (n = 30)
Full size table
Table 6 Clinical characteristics and treatment of Behçet’s Disease according to disease activity (n = 30)
Full size table

Regarding anxiety and depression levels, they were significantly higher among active BD patients than in the inactive BD group. BD activity was associated with a high level of sleep disturbance, including a high level of insomnia (p = 0.008) and daytime sleepiness (p = 0.007) (Table 7). Domains significantly higher for the active BD group included sleep onset latency, sleep efficiency, and disturbed sleep (p = 0.017, p = 0.033, and p = 0.033, respectively (Table 8). Behçet’s disease activity was associated with significantly lower values regarding the SF-36 QOL scale (Table 9).

Table 7 Laboratory data, HAM-A, HAM-D, ISI, and ESS of Behçet’s Disease patients according to disease activity (n = 30)
Full size table
Table 8 Pittsburgh Sleep Quality Index for Behçet’s Disease patients according to disease activity (n = 30)
Full size table
Table 9 Health status and quality of life assessment for Behçet’s Disease patients according to disease activity (n = 30)
Full size table

In this study, Krause’s BD activity assessment, referred to as clinical severity score, showed a significantly positive correlation with anxiety, depression, VDI, and BDCAF (P < 0.001) (Table 10), an insignificant correlation with PSQI (Table 11) while showing significantly negative correlation with SF-36 QOL domains (Table 12).

Table 10 Correlation of disease duration, disease severity, VDI, and BDCAF with other parameters for Behçet’s Disease group (n = 30)
Full size table
Table 11 Correlation of disease duration, disease severity, VDI, and BDCAF with PSQI components for Behçet’s Disease group (n = 30)
Full size table
Table 12 Correlation of disease duration, disease severity, VDI, and BDCAF with SF-36 domains for Behçet’s Disease group (n = 30)
Full size table

The VDI was associated with a significantly positive correlation with anxiety, depression, disease severity, and BDCAF (P = 0.001, p = 0.002, P < 0.001 and P < 0.001; respectively) (Table 10), insignificant correlation with PSQI (Table 11) while showed significantly negative correlation with almost all SF-36 QOL domains (Table 12).

BDCAF was associated with a significantly positive correlation with anxiety, depression, disease severity, VDI (P < 0.001), and ESS (p = 0.048) (Table 10), with an insignificant correlation with PSQI (Table 11) while showing a significantly negative correlation with all SF-36 QOL domains (Table 12).

Discussion

Worldwide the prevalence of BD is estimated to be 5.2/per 100,000 population [24]. BD is common in Asia and the Mediterranean Sea region and is considered the most common vascular disease in Egypt [25]. Sex predominance is still a matter of debate in the literature. Still, it has been reported in many studies that the course of the disease is more aggressive in the male gender [26]. The disease is expected in the third and fourth decades with rare occurrence in children and adults over 50 years [27].

Behçet’s disease is a chronic multisystem disorder with different systemic manifestations. Oral and genital ulcers represent the most common clinical manifestations of BD; reported in 50 -85% of patients [28, 29]. Arthritis and arthralgia are common in up to 50% of BD patients [30]. Ophthalmic affection is common in about 70% in males and 30% in females [31]. Neurological affection is common in 5–10% of BD patients with male predominance and a recognized latency period of about five years from initial diagnosis [32].

Gastrointestinal (GIT) manifestation is common in East Asia; about 50% of patients in Japan have GIT symptoms, while in the Mediterranean region, GIT involvement is infrequent [33]. Zhang et al. (2015) enrolled 119 patients with BD, and 14% had pulmonary involvement. All patients had venous thromboembolism; a pulmonary artery aneurysm was detected in 6 patients; 5 had pulmonary parenchymal affection, and 3 had isolated pulmonary embolism [34].

In the current study, we observed a male predominance of 80% with a mean age of 34.7 ± 8.8; the most commonly observed symptoms were fatigue (43%), fever (33%), and oral and genital ulceration (36%). The mean duration of the disease was 8.34 ± 5.18 in the active BD vs. 5.85 ± 2.73 in the inactive group, with mean BDCAF 4.15 ± 1.28 vs. 1.05 ± 0.66. The severity index of the active BD group was 5.62 ± 1.26 compared to 0.18 ± 0.39 and VDI 4.08 ± 2.13 versus 0.53 ± 0.62 for the inactive BD group.

Regarding VDI, Elgengehy et al. (2021) studied the impact of VDI on the course and severity of BD in relation to clinical manifestations and comorbidities. They observed a mean VDI of 3.5 ± 1.8, which was significantly associated with total thrombosis, neurological manifestation, and impaired vision this was correlated to the use of immunosuppressive treatment, especially cyclophosphamide, and anti-TNF and was significantly correlated with age and disease duration [12].

BD pathophysiology is complex, with genetic and altered immune system responses behind the different systemic manifestations observed during BD. Family history is common in up to 10% of patients [35].

Vascular involvement is the key factor for the systemic manifestation of Behçet’s disease, with venous involvement predominance over arterial involvement. The arterial aneurysm is also a common presentation [36].

HLA-B51/B5 carriers are at more risk of developing BD than others; the role of HLA-B51/B5 in the development of BD manifestations is through the presentation of CD8 + T cells and Killer immunoglobulin-like receptors of NK cells [37]. In other studies, there was a significant reduction in interleukin 10 (IL10) in BD patients, another polymorphism in the IL-23R gene is detected, and among possible etiological mechanisms are the association of BD with CCR1 and KLRC4 Chemoreceptors which regulate the release of IL-12 and IL-23 [38].

The heterogenicity of the immunological profile and the difference in clinical manifestation is associated with the emergence of 4 phenotypes of BD; mucocutaneous, superficial and deep venous thrombosis, ophthalmic, and articular type.

Anxiety and depression are among the most common neuropsychiatric manifestations of BD, occurring in around 86% of patients [7]. The pathogenesis of anxiety and depression in BD is unclear and may be related to disease progression, functional decline, CNS affection, and use of corticosteroid drugs [39]. However, a combined interaction between acute stress in the course of the disease and alteration in the immune system could be an acceptable explanation.

In our study, we observed high levels of anxiety and depression among BD patients compared to healthy controls. Also, levels of anxiety and depression were significantly higher among the active disease group.

In concomitant with our results, Taner and colleagues (2007) compared anxiety and depression in 2 groups of BD; they enrolled 112 BD patients and 95 BD patients with psoriasis using Beck’s depression & anxiety inventory test. More than 50% of patients of both groups had anxiety and depression, with an increased risk of 12 folds in BD patients with a disease course of more than three years [40]. Also, Monastero et l., (2004) enrolled 26 BD patients finding that depression and anxiety were more in the diseased group than the control group [39].

In agreement with our study, Çalıkoglu et al. enrolled 23 BD patients with psoriasis finding depression and anxiety were more in the diseased group than the control group [41]. In a study of 155 BD patients (86 males, 69 females with a median age of 37) compared to 107 control using Hospital Anxiety and Depression (HADS) scale; 76.7% had active disease, 43.2% of patients exhibited anxiety, and 40.6% suffered from depression, anxiety, and depression were significantly higher among active disease patients with positive correlation with ESR [42]. Also, anxiety and depression were higher in patients with high Multidimensional Assessment of Fatigue (MAF) scores, and there was no significant correlation with different symptoms.

Yazmalar et al. (2017), studying 112 BD patients and 67 control participants using HADS, revealed that anxiety and depression were higher in BD patients than in controls. PSQI with all components and Global score was significantly higher in BD patients than in control (7.91 ± 4.65 vs. 4.58 ± 2.78, p= 0.001) [4].

Disturbance of sleep patterns in patients with BD is related to variable systemic affection, anxiety, depression, limitation of activity, and medical treatment. Many sleep disorders have been reported in BD patients, including obstructive sleep apnea syndrome (OSAS), concerning the increased serum level of leptin, adiponectin, and resistin [43]. Also, Tascilar et al. (2012) reported restless leg syndrome in patients with BD [44].

Some BD manifestations as genital ulceration, were reported to be associated with difficulty in initiating sleep in BD patients and increasing rapid eye movement (REM) sleep. Arthralgia was reported to be negatively correlated with REM sleep latency [45]. Total sleep time and time in bed were negatively correlated with ophthalmic manifestations of BD [46].

We observed that patients self-reported a high degree of insomnia and daytime dysfunction among BD patients compared to control participants (p < 0.001). All domains of PSQI, including sleep quality, duration, efficiency, disturbance, drugs, sleep onset latency, and daytime dysfunction, were significantly higher among the BD group. Active disease assessed using BDCAF was associated with higher scores of ISI, ESS, and selective domains of PSQI, including sleep efficiency, disturbance, and sleep onset latency.

Tascilar et al. assessed the relationship between sleep disorders in Behçet’s disease in relation to fatigue and QOL; they enrolled 51 BD patients and 21 healthy controls, reporting a mean HAM-D score of 10.7 ± 8.6 and mean HAM-A score of 14.98 ± 11.9 in patients with BD which was significantly higher than control, respectively. Regarding sleep disturbance, insomnia was the most common presentation in 50.9% of patients, RLS in 35.3%, and there was a significant difference in all components of PSQI [44].

Koca et al. (2015) studied the relationship between BD activity, depression, and sleep quality; enrolled 40 BD patients and 30 healthy controls, revealing a significant positive correlation between Beck’s depression inventory (BDI) and BDCAF (r = 0.559, p = 0.001), and also significant positive correlation BDI and PSQI (r = 0.617, p = 0.001). The study also revealed a significant difference between the BD group and control regarding BDI score (12.4 ± 7.62 vs. 5.1 ± 1.42, p = 0.012) and regarding PSQI global score (6.4 ± 4.44 vs. 3.1 ± 1.33, p= 0.02) [47].

Lee et al. (2017), studying the association of sleep quality in BD patients with disease activity, depression, and QOL, enrolled 100 BD patients; according to PSQI using cut off value of 9; patients were grouped into good sleepers (58 patients) and poor sleepers (42 patients). Poor sleep was observed in patients with higher BDI scores and BDCAF. Among the 7 PSQI components, daytime dysfunction was higher in patients with high disease activity (p = 0.03). Total PSQI scores were strongly correlated with BDCAF, BDI-2, Behçet’s disease quality of life measure (BD QOL), and pain VAS score (p = 0.02, p < 0.001, p < 0.001, and p< 0.001, respectively) [48].

Many etiological factors have been reported to decrease quality of life (QoL) in patients with BD; the chronicity of the disease and its relapsing course with deterioration of physical and mental functions can explain that finding [49].

In a study of 123 BD patients vs. 123 healthy controls to assess QOL in patients of BD in relation to symptoms and disease activity using BDCAF and VDI to assess severity, the SF-36 QOL scale was lower in all domains among the BD group with a significant difference in general health, vitality, and physical health domains. Also, BDCAF was associated with a significant negative correlation with all domains of the SF-36 QOL scale [50].

Zulfiqar et al. (2020) studied the correlation between the disease activity of BD and the psychological condition of patients; they enrolled 102 patients; oral ulceration was found in the initial assessment in 69% of patients, genital ulcers in 29% of patients, arthralgia in 53%. They assessed for each unit increase in Behçet’s Disease Activity Index (BDAI); the decline or increase in; the European Quality of Life Five Dimensions Five Level scale (EQ-5D-5L) was − 0.01, Work and Social Adjustment Scale (WSAS) was − 0.02, Patient Health Questionnaire-9 (PHQ-9) was 0.14, General Anxiety Disorder-7 (GAD-7) was 0.41, Warwickshire-Edinburgh Mental Wellbeing Scale (WEMWBS) was − 0.53 [51].

Ertam et al. enrolled 195 patients and 195 control SF-36 and WHO QOL-100 scale scores. The overall SF-36 and WHOQOL-100 scale scores, as well as their domains, were significantly lower in BD patients. General health and role-physical domains of SF-36 showed significantly negative linear correlations with Krause’s clinical severity score [52].

Conclusion

Based on the evaluation of HAM-A, HAM-D, and SF-36 scores, levels of anxiety and depression are high in BD patients; quality of life is impaired in BD, and these impairments are related to disease activity and severity. Sleep quality also is markedly affected in BD, with some domains affected more than others. These results highlight the importance of managing psychological comorbidities experienced by patients and taking measures to improve sleep quality and quality of life.

Limitations of the study

Limited sample of selected patients was recruited in a single-center stud. Also, the need for specific diagnostic tools, including sleep study evaluation of the study population, may limit the generalization of the results.

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

BD:

Behçet’s disease

BDAI:

Behçet’s Disease Activity Index

BDCAF:

Behçet's Disease Current Activity Form

BDI-II:

Beck Depression Inventory II

CRP:

C-reactive protein

ESR:

Erythrocyte sedimentation rate

ESS:

Epworth sleepiness scale

GIT:

Gastrointestinal

HADS:

Hospital Anxiety and Depression Scale

HAM-A:

Hamilton’s anxiety rating scale

HAM-D:

Hamilton’s depression rating scale

IL:

Interleukin

ISI:

Insomnia severity index

MAF:

Multidimensional Assessment of Fatigue score

OSAS:

Obstructive sleep apnea syndrome

PSQI:

Pittsburgh Sleep Quality Index

QOL:

Quality of life

REM:

Rapid eye movement

SF-36 QOL:

Short Form 36 Quality Of Life Scale

SpO2:

Saturation of peripheral oxygen

VDI:

Vasculitis damage index

WHOQOL:

World Health Organization Quality of Life

References

  1. Behcet HJ (1937) Uber rezidivierende, aphtose, durch ein virus verursachte geschrwre am mund, am auge und an den genitalien. Dermatol Wochenschr 105:1152–1157

    Google Scholar 

  2. Sariyildiz MA, Batmaz I, Budulgan M, Bozkurt M, Yazmalar L, Inanir A, Celepkolu T, Cevik R (2013) Sleep quality in patients with systemic sclerosis: relationship between the clinical variables, depressive symptoms, functional status, and the quality of life. Rheumatol Int 33:1973–9

    Article  PubMed  Google Scholar 

  3. Batmaz I, Sarıyıldız MA, Dilek B, Bez Y, Karakoç M, Çevik R (2013) Sleep quality and associated factors in ankylosing spondylitis: relationship with disease parameters, psychological status and quality of life. Rheumatol Int 33:1039–45

    Article  PubMed  Google Scholar 

  4. Yazmalar L, Batmaz İ, Sarıyıldız MA, Yıldız M, Uçmak D, Türkçü F, Akdeniz D, Sula B, Çevik R (2017) Sleep quality in patients with Behcet’s disease. Int J Rheum Dis 20(12):2062–9

    Article  PubMed  Google Scholar 

  5. Noel N, Bernard R, Wechsler B, Rescherigon M, Depaz R, Le Thi Huong Boutin D, Piette JC, Drier A, Dormont D, Cacoub P, Saadoun D (2014) Long-term outcome of neuro-Behçet’s disease. Arthritis Rheumatol. 66(5):1306–14

    Article  PubMed  Google Scholar 

  6. Hirohata S, Kikuchi H, Sawada T, Nagafuchi H, Kuwana M, Takeno M, Ishigatsubo Y (2012) Clinical characteristics of neuro-Behcet’s disease in Japan: a multicenter retrospective analysis. Modern Rheumatol 22(3):405–13

    Article  Google Scholar 

  7. Epstein RS, Cummings NA, Sherwood EB, Bergsma DR (1970) Psychiatric aspects of Behçet’s syndrome. J Psychosom Res 14(2):161–72

    Article  CAS  PubMed  Google Scholar 

  8. International Team for the Revision of the International Criteria for Behçet’s Disease (ITR-ICBD), Davatchi F, Assaad-Khalil S, Calamia KT, Crook JE, Sadeghi-Abdollahi B, Schirmer M, Tzellos T, Zouboulis CC, Akhlagi M, Al-Dalaan A (2014) The International Criteria for Behçet’s Disease (ICBD): a collaborative study of 27 countries on the sensitivity and specificity of the new criteria. J Eur Acad Dermatol Venereol 28(3):338–47

    Article  Google Scholar 

  9. Bhakta BB, Brennan P, James TE, Chamberlain MA, Noble BA, Silman AJ (1999) Behcet’s disease: evaluation of a new instrument to measure clinical activity. Rheumatol 38(8):728–33

    Article  CAS  Google Scholar 

  10. Türsen Ü (2009) Activation markers in Behcet disease. Turkderm 43:74–86

    Google Scholar 

  11. Exley AR, Bacon PA, Luqmani RA, Kitas GD, Gordon C, Savage CO, Adu D (1997) Development and initial validation of the vasculitis damage index for the standardized clinical assessment of damage in the systemic vasculitides. Arthritis Rheum 40(2):371–80

    Article  CAS  PubMed  Google Scholar 

  12. Elgengehy FT, Gamal SM, Sobhy N, Siam I, Soliman AM, Elhady GW, Gheita TA (2021) Vasculitis damage index in Behçet’s disease. Adv Rheumatol 61:33

    Article  PubMed  Google Scholar 

  13. Hamilton M (1959) The assessment of anxiety states by rating. British Journal of Medical Psychology 32:50–55. https://doi.org/10.1111/j.2044-8341.1959.tb00467.x

    Article  CAS  PubMed  Google Scholar 

  14. Hamilton M (1960) Depression rating scale. Neurol Neurosurg. Psychiatry 23:56–62

    CAS  Google Scholar 

  15. Kendrick T, Pilling S, Mavranezouli I, Megnin-Viggars O, Ruane C, Eadon H, Kapur N, Committee Guideline (2022) Management of depression in adults: summary of updated NICE guidance. BMJ 378:o1557

    Article  PubMed  Google Scholar 

  16. Bastien CH, Vallières A, Morin CM (2001) Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2(4):297–307

    Article  PubMed  Google Scholar 

  17. Morin CM, Belleville G, Bélanger L, Ivers H (2011) The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 34(5):601–608

    Article  PubMed  PubMed Central  Google Scholar 

  18. Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14(6):540–5

    Article  CAS  PubMed  Google Scholar 

  19. Ahmed AE, Fatani A, Al-Harbi A, Al-Shimemeri A, Ali YZ, Baharoon S, Al-Jahdali H (2014) Validation of the Arabic version of the Epworth sleepiness scale. J Epidemiol Glob Health 4(4):297–302

    Article  PubMed  PubMed Central  Google Scholar 

  20. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ (1989) The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 28(2):193–213

    Article  CAS  PubMed  Google Scholar 

  21. Suleiman KH, Yates BC, Berger AM, Pozehl B, Meza J (2010) Translating the Pittsburgh sleep quality index into Arabic. West J Nurs Res 32(2):250–68

    Article  PubMed  Google Scholar 

  22. Ware JE Jr, Sherbourne CD. (1992) The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 30(6):473-83. PMID: 1593914

  23. Al Abdulmohsin, Saud Abdulaziz. (1997) Translation of the RAND 36-Item Health Survey 1.0 (Aka SF-36) into Arabic. Santa Monica, Calif: Rand

  24. Calamia KT, Wilson FC, Icen M, Crowson CS, Gabriel SE, Kremers HM (2009) Epidemiology and clinical characteristics of Behçet’s disease in the US: a population-based study. Arthritis Rheum 61:600–604

    Article  PubMed  PubMed Central  Google Scholar 

  25. Attia DHS, Noor RAA, Salah S (2019) Shedding light on vasculitis in Egypt: a multicenter retrospective cohort study of characteristics, management, and outcome. Clin Rheumatol 38:1675–1684

    Article  PubMed  Google Scholar 

  26. Yazici H, Tüzün Y, Pazarli H, Yurdakul S, Ozyazgan Y, Ozdoğan H et al (1984) Influence of age of onset and patient’s sex on the prevalence and severity of manifestations of Behçet’s syndrome. Ann Rheum Dis 43:783–789

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Ideguchi H, Suda A, Takeno M, Ueda A, Ohno S, Ishigatsubo Y (2011) Behçet disease: evolution of clinical manifestations. Medicine (Baltimore) 90:125–132

    Article  PubMed  Google Scholar 

  28. Behçet H, Gozcu N (1938) Uç nahiyede nuksi tavazzular yapan ve hususi bir virus tesiriyle umumi intan hasil ettigine kanaatimiz artan (Entite morbide) hakkinda. Deri Hastaliklari ve Frengi Kliniği Arsivi 5:1863–1873

    Google Scholar 

  29. Alpsoy E, Donmez L, Onder M, Gunasti S, Usta A, Karincaoglu Y et al (2007) Clinical features and natural course of Behçet’s disease in 661 cases: a multicenter study. Br J Dermatol 157:901–906

    Article  CAS  PubMed  Google Scholar 

  30. Yurdakul S, Yazici H, Tüzün Y, Pazarli H, Yalçin B, Altaç M (1938) The arthritis of Behçet’s disease: a prospective study. Ann Rheum Dis 42:505–515

    Article  Google Scholar 

  31. Tugal-Tutkun I, Onal S, Altan-Yaycioglu R, HuseyinAltunbas H, Urgancioglu M (2004) Uveitis in Behçet disease: an analysis of 880 patients. Am J Ophthalmol 138:373–380

    Article  PubMed  Google Scholar 

  32. Uluduz D, Kürtüncü M, Yapıcı Z, Seyahi E, Kasapçopur Ö, Özdoğan H et al (2011) Clinical characteristics of pediatric onset neuro-Behçet’s disease. Neurology 77:1900–1905

    Article  CAS  PubMed  Google Scholar 

  33. Cheon JH, Çelik AF, Kim WH (2010) Behçet’s disease: Gastrointestinal involvement. In: Yazici Y, Yazici H (eds) Behçet’s Syndrome, 1st edn. Springer, New York, pp 165–188

    Chapter  Google Scholar 

  34. Zhang X, Dai H, Ma Z, Yang Y, Liu Y (2015) Pulmonary involvement in patients with Behçet’s disease: report of 15 cases. Clin Respir J 9(4):414–22

    Article  PubMed  Google Scholar 

  35. Gül A, Ohno S (2010) Genetics of Behçet’s disease. In: Yazici Y, Yazici H (eds) Behçet’s Syndrome, 1st edn. Springer, New York, pp 265–276

    Chapter  Google Scholar 

  36. Ideguchi H, Suda A, Takeno M, Ueda A, Ohno S, Ishigatsubo Y (2011) Characteristics of vascular involvement in Behçet’s disease in Japan: a retrospectif cohort study. Clin Exp Rheumatol 29:47–53

    Google Scholar 

  37. de Menthon M, Lavalley MP, Maldini C, Guillevin L, Mahr A (2009) HLAB51/B5 and the risk of Behçet’s disease: a systematic review and meta-analysis of case control genetic association studies. Arthritis Rheum 61:1287–1296

    Article  PubMed  Google Scholar 

  38. Fresko I (2012) Meeting report 15th International Congress on Behçet’s Disease. Clin Exp Rheumatol 30(72):S118–S128

    CAS  PubMed  Google Scholar 

  39. Monastero R, Camarda C, Pipia C, Lopez G, Camarda LK, Baiamonte V, Ferrante A, Triolo G, Camarda R (2004) Cognitive impairment in Behçet’s disease patients without overt neurological involvement. J Neurol Sci 220(1–2):99–104

    Article  PubMed  Google Scholar 

  40. Taner E, Coşar B, Burhanoğlu S, Calikoğlu E, Onder M, Arikan Z (2007) Depression and anxiety in patients with Behçet’s disease compared with that in patients with psoriasis. Int J Dermatol 46(11):1118–24

    Article  PubMed  Google Scholar 

  41. Calikoglu E, Onder M, Cosar B, Candansayar S (2001) Depression, anxiety levels and general psychological profile in Behçet’s disease. Dermatology 203(3):238–240

    Article  CAS  PubMed  Google Scholar 

  42. Can Sandikci S, Colak S, Omma A, Enecik ME (2019) An evaluation of depression, anxiety and fatigue in patients with Behçet’s disease. Int J Rheum Dis 22(6):974–9

    Article  PubMed  Google Scholar 

  43. Kim SK, Choe JY, Park SH, Lee SW, Lee GH, Chung WT (2010) Increased insulin resistance and serum resistin in Korean patients with Behçet’s disease. Arch Med Res 41(4):269–74

    Article  CAS  PubMed  Google Scholar 

  44. Tascilar NF, Tekin NS, Ankarali H, Sezer T, Atik L, Emre U, Duysak S, Cinar F (2012) Sleep disorders in Behçet’s disease, and their relationship with fatigue and quality of life. J Sleep Res 21(3):281–8

    Article  PubMed  Google Scholar 

  45. Ditmer M, Gabryelska A, Turkiewicz S, Białasiewicz P, Małecka-Wojciesko E, Sochal M (2022) Sleep problems in chronic inflammatory diseases: prevalence, treatment, and new perspectives: a narrative review. J Clin Med 11(1):67

    Article  CAS  Google Scholar 

  46. Léger D, Stal V, Quera-Salva MA, Guilleminault C, Paillard M (2001) Disorders of wakefulness and sleep in blind patients. Rev Neurol 157(11 Pt 2):S135-9

    PubMed  Google Scholar 

  47. Koca I, Savas E, Ozturk ZA, Tutoglu A, Boyaci A, Alkan S, Kisacik B, Onat AM (2015) The relationship between disease activity and depression and sleep quality in Behçet’s disease patients. Clin Rheum 34:1259–63

    Article  Google Scholar 

  48. Lee J, Kim SS, Jeong HJ, Son CN, Kim JM, Cho YW, Kim SH (2017) Association of sleep quality in Behcet disease with disease activity, depression, and quality of life in Korean population. Korean J Intern Med 32(2):352

    Article  PubMed  PubMed Central  Google Scholar 

  49. Bernabe E, Marcenes W, Mather J, Phillips C, Fortune F (2010) Impact of Behçet’s syndrome on health-related quality of life: influence of the type and number of symptoms. Rheum 49(11):2165–71

    Article  Google Scholar 

  50. Khabbazi A, Attari VE, Jafarabadi MA, Mahdavi AM (2021) Quality of life in patients with Behçet disease and its relation with clinical symptoms and disease activity. Reum Clín (English Edition) 17(1):1–6

    Article  Google Scholar 

  51. Zulfiqar MH, Shamdas M, Bashir A, Douglas S, Murray PI (2020) Longitudinal study investigating the relationship between disease activity and psychological status of patients with Behçet’s disease. Ocul Immunol Inflamm 28(4):613–21

    Article  PubMed  Google Scholar 

  52. Ertam I, Kitapcioglu G, Aksu K, Keser G, Ozaksar A, Elbi H, Unal I, Alper S (2009) Quality of life and its relation with disease severity in Behçet’s disease. Clin Exp Rheum 27(2):S18

    CAS  Google Scholar 

Download references

Acknowledgements

None.

Funding

None.

Author information

Authors and Affiliations

  1. Chest Department, Faculty of Medicine, Assiut University Hospital, Assiut, 71515, Egypt

    Ahmad M. Shaddad, Aliaë A. R. Mohamed Hussein & Waleed Gamal Elddin Khaleel

  2. Neuropsychiatry Department, Faculty of Medicine, Assiut University Hospital, Assiut, 71515, Egypt

    Shady Mohamed Safwat

  3. Department of Rheumatology, Rehabilitation and Physical Medicine, Assiut University Hospital, Assiut, 71511, Egypt

    Esraa A. Talaat, Sara Farrag & Nada M. Gamal

Authors
  1. Ahmad M. Shaddad
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Aliaë A. R. Mohamed Hussein
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shady Mohamed Safwat
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Esraa A. Talaat
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sara Farrag
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Nada M. Gamal
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Waleed Gamal Elddin Khaleel
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

AMS, EAT and WGE conception and design. SMS, EAT, SF and NMG: data collection. AMS and WGE: statistical analysis. AMS, AARMH, SF and WGE: medical writing. All authors revised the manuscript. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Ahmad M. Shaddad.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the institutional review board and ethical committee of Faculty of Medicine- Assiut University in compliance with the Helsinki Declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shaddad, A.M., Hussein, A.A.R.M., Safwat, S.M. et al. Assessment of sleep quality, anxiety, depression, and quality of life in Behçet’s disease. Egypt J Bronchol 17, 26 (2023). https://doi.org/10.1186/s43168-023-00200-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s43168-023-00200-x

Keywords