研究目的：失眠影響國人身心健康甚多，藥物取向治療為當代最廣泛的失眠治療方式。研究顯示許多失眠患者，可藉由短期服用助眠藥物改善失眠，避免個體失眠慢性化，且於停藥後未有任何藥物副作用困擾。然而，臨床上仍觀察到不少個案，對助眠藥物產生依賴，需長期服用助眠藥物，此舉不僅造成醫療資源之浪費，其安全性與有效性仍受爭議。而心理因素在藥物依賴扮演重要的角色，同樣是長期服用助眠藥物，不同的助眠藥物使用者卻可能存有相異的用藥心態，因此助眠藥物使用者的用藥行為以及用藥相關心態，可能會組合成不同的用藥型態，而探討助眠藥物之不同使用型態與其心理機轉，有助於進一步瞭解助眠藥物使用現象。故本研究旨在用量化方法探討助眠藥物使用型態之差異，試圖將不同的助眠藥物使用型態進行分群，並提出可能影響助眠藥物使用型態的相關因子。 研究方法與結果：本研究招募了272名曾經或目前正在服用助眠藥物的使用者填寫研究問卷，透過對兩個外顯用藥行為變項（用藥總時間、用藥頻率）與六個用藥相關心理變項（對助眠藥物的渴求程度、對助眠藥物的正、負向態度、主觀規範、以及促進、抑制之知覺控制）的集群分析，我們將助眠藥物使用型態分為「慣性使用」、「矛盾依賴」、「控制使用」以及「輔助使用」四種型態。在外顯用藥行為方面，「慣性使用」集群與「矛盾依賴」集群皆展現較長的用藥時間與高頻率的使用，「控制使用」群集與「輔助使用」群集則展現較短的用藥時間與低頻率的使用。然而，四組群集皆展現其獨特的心理特徵。「慣性使用」群集對助眠藥物的渴求程度最強，正向態度比負向態度高，主觀認為重要他人支持自己服用助眠藥物，傾向持續服用助眠藥物；「矛盾依賴」群集呈現對助眠藥物正向與負向態度皆高的矛盾狀態，且主觀認為自己無法控制藥物之使用；「控制使用」群集雖也對助眠藥物出現正向、負向態度皆高的表現，但其可對藥物使用進行控制；「輔助使用」群集的個案對於助眠藥物的負向態度高於正向態度，藥物渴求程度低，且傾向避免使用助眠藥物。多項式邏輯斯回歸的分析結果則進一步顯示年齡較大、失功能睡眠信念問卷分數較高的個案，較容易落入「慣性使用」組；被診斷過情緒疾患、失眠時間較長、睡前激發程度問卷分數較高的個案，較容易落入「矛盾依賴」組；受教育年限較高的個案，較傾向落入「控制使用」組；最後，年紀較輕、失功能睡眠信念問卷分數較低的個案，則容易落入「輔助使用」組。 結論：本研究結果顯示相似的用藥行為仍有相異的用藥相關心理狀態，且部分心理相關變項可能會影響助眠藥物之使用型態，故推測用藥心理與助眠藥物使用者的特質扮演影響用藥型態的重要因素。此結果可提供臨床工作者，初步了解助眠藥物使用之心理機轉，亦能將其運用於協助不同類型的安眠藥物使用者擬訂減藥處遇。 / Purpose：Insomnia has great impact on people's health in Taiwan. Pharmacological approaches are the most commonly used treatment for insomnia. Although short-term hypnotic use could improve sleep, however some patients use hypnotics for a prolonged period of time and have difficulty to discontinue using them. This would lead to great cost of the individuals and societies. Psychological factors have been found to play an essential role in the long-term use of other substances. Clinical observation also showed that there were individual differences in the psychological aspects of medication use in spite of similar medication use behaviors. Therefore, it is possible to use hypnotic-related behaviors and psychological factors to categorize hypnotic users in order to further the understanding the mechanism underlying chronic hypnotic use. The purpose of this research is to identify hypnotic use patterns by exploratory quantitative method and the characteristics associated with different hypnotic usage patterns. Methods and Results: 272 previous or current hypnotic users were recruited to complete a package of questionnaires. Through cluster analysis with two explicit medication behavior variables (total duration of hypnotic use, frequency of hypnotic use) and six hypnotic-related psychological variables (craving for hypnotic, positive and negative attitudes towards hypnotic, subjective norm, facilitating and inhibiting perceived behavioral control), four hypnotic usage patterns were identified, which were “habitual use”, “paradoxical dependence”, “controlling use”, and “supplementary use”. In terms of explicit medication behaviors, “habitual use” and “paradoxical dependence” clusters both show longer time and higher frequency of hypnotic use. On the other hand, “controlling use” and “supplementary use” clusters showed similar medication use behaviors with shorter duration and lower frequency of hypnotic use. In addition, the four clusters exhibited different psychological profiles. Users in “habitual use” cluster have strongest craving for hypnotic, higher positive than negative attitude toward hypnotic use, and believe that significant others support their medication behavior. Users in “paradoxical dependence” cluster showed paradoxical attitude toward hypnotics, and reported less control over their hypnotic use. Users in “controlling use” cluster also had paradoxical attitude toward hypnotic, but their craving level of hypnotic was lower than users in “paradoxical dependence” cluster. In addition, users in “controlling use” cluster feel they can control their hypnotic use. Users in “supplementary use” cluster had lowest craving level, higher negative attitude toward hypnotic, and tend to avoid taking hypnotic when possible. Multiple logistic regression further showed that (1) people with older age or higher score on the Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS) tend to classified into “habitual use” cluster; (2) people with mental disorder diagnosis, long history of insomnia, or higher score in Pre-Sleep Arousal Scale (PSAS) tend to be classified into the "paradoxical dependence " cluster; (3) patient with more years of education more likely fall into “controlling use” cluster, finally, (4) the hypnotic users who are younger or lower score in DBAS are easier classified into the “supplementary use ” cluster. Conclusions：The results of the current study indicates that similar medication behavior could have different hypnotic-related psychological status. Therefore, psychological factors are needed to be assessed in order to understand the process of long-term hypnotic use. The results provides a further understanding of the psychological mechanisms of hypnotic use, and also help clinician in related-field to develop insomnia treatment plan or hypnotic discontinuation program based on insomniacs’ characteristics and their psychological variable toward hypnotic use.

研究目的 本研究的目的是要藉由線索暴露的實驗典範,探索長期使用安眠藥物 之患者對於安眠藥物相關刺激的注意力偏誤現象,並根據 Baker 及其同事們 (2004)與其他學者所提出的「藥物動機理論的情感模型」,強調負向情感在長 期使用安眠藥物的失眠患者所扮演的角色,本研究另欲探討長期使用失眠藥物的 患者是否在負向的情緒下能引發其對安眠藥物有更多的注意力及反應偏誤,並以 oddball 實驗典範來引發測量大腦皮質 ERP 波的注意力偏誤現象,並試圖以主觀 渴求問卷來測量個案是否在負向情感下有較強烈的主觀渴求反應。 方法 研究之有效樣本為 13 人。其中男性 5 人,女性 8 人,年齡介於 23-54 歲 (34.15 ± 11.07),參與研究之受試者會進行兩晚之實驗及多頻道睡眠生理檢查, 實驗情境分成基礎情境及挫折情境,在挫折情境中,受試者在進行較困難之認知 作業的同時,研究者會給予負向之指導語以進行情緒之操弄;而在基礎情境則給 予中性之指導語。在認知作業進行之後,開始進行線索暴露之 ERP 測量,受試 者須判斷圖片是否含有動物(目標刺激),另包含中性圖片刺激(96 張)、睡眠 相關刺激(32 張)及藥物相關刺激(32 張)。另外在認知測驗及線索暴露的前後 也會測量受試者之情緒狀態及主觀渴求狀態。研究分析以多變量變異數分析進行 檢驗。 結果 長期使用安眠藥物的患者相較於中性刺激,其對於藥物圖片刺激及睡眠相 關刺激皆有較大之 P300 及 SPW 腦波振幅。未在研究中驗證 Baker 等人提出之負 增強處理模式之因果關係,但發現,在基礎情境中,當受試者的正向情緒減少愈 多,受試者在單一題項渴求程度減少愈少;而負向情緒與其他的渴求指標較具有 相關性,研究發現當負向情緒增加愈多,單一題項渴求程度增加愈多,對藥物效 果的期待也愈高,對藥物的欲求與所帶來欣快感也會愈高,顯示情緒的改變於主 觀渴求狀態的相關性。此外本研究結果顯示客觀的腦波指標與部分主觀感受顯著 相關,其中 P300 與其對藥物的渴求程度呈正相關。 結論 無論是在基礎情境或挫折情境,長期使用安眠藥物之患者對安眠藥刺激及 睡眠相關刺激皆有注意力偏誤之現象,且此注意力偏誤現象與其對藥物的渴求程 度具有一定程度之相關性。在挫折情境中,受試者對藥物之主觀渴求有較大的傾向。 / Introduction The major goal of this study is to examine the phenomenon of craving in hypnotic use. The Affective Processing Model of Negative Reinforcement (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004) suggests that negative affect would influence drug use through the change of cognitive process to a “hot information processing” and therefore increase the craving for drug use. The study explores the effects of negative affect on attentional bias and subjective craving associated with hypnotic use to test this model. Method Thirteen long-term hypnotic users were included in this study. They came to the sleep laboratory for two nights for an experimental night in which negative affect was induced by giving negative comments on their performance on a cognitive task and a control night with exactly the same procedure except that the negative comments was replaced by neutral comments. For both nights, craving was assessed with subjective ratings and measure of attentional bias with recording of event-related potentials (ERPs) induced by pictures related to hypnotic use, sleep and neutral pictures. Result The amplitude of P300 and SPW for sleep related pictures and hypnotic related pictures are significant larger than the amplitude for neutral pictures in both conditions. Also, results show that the picture of P300 are positively correlated with subjective craving for hypnotic drugs. Moreover, the data shows the tendency of condition difference in subjective craving. Conclusion The hypnotic long-term users do show attentional bias for sleep related and hypnotic related pictures. However, the result does not show more attentional bias for hypnotic related pictures in stressful situation. On the other hand, the data shows a tendency that the subjective craving is stronger in stressful situation than in baseline situation. The findings show only partial support for the Affective Processing Model of Negative Reinforcement.