(神経系理学療法2)

科学研究費補助金 研究種目:一般研究(B)(2) 課題番号:06452303 研究代表者:山下 哲郎 研究期間:1994-1996年度

工作權係為人類之基本人權，因此，各國政府莫不致力於加強身心障礙者各項權益之保障與人力資源之開發，而我國政府亦然。近年來，由於慢性精神病患人數不斷逐年的增加，且其中之憂鬱症更被視為是現代人的文明病。因此，如何面對社會上不斷加增的慢性精神病患者，並試著給予其就業權適度的保障是政府與社會大眾無法逃避的責任與情況。事實上，目前已有許多的研究顯示，諸多種類的精神疾病（例如憂鬱症）都是可以治癒且癒後良好的疾病，只要經過適當的治療，病人便能如正常人一般的正常工作與生活，更能為社會貢獻其一己之力。可惜，由於我國政府對於慢性精神疾病患者權益保障的各項措施仍感陌生，加上社會大眾普遍存有的刻板印象，造成慢性精神病患者就業率與工作待遇普遍偏低的歧視現象。因此，對於慢性精神疾病患者就業權益之保障方面，我國政府著實仍有許多需要改善之處。 本文期望藉由法規與文獻的探討，配合訪談資料的分析，來發現慢性精神病患者（特別是憂鬱症患者），在就業保障方面的問題，並試著提出改進之建議。因此，各章的內容如下：第一章安排基本的研究架構，第二章則從事相關理論的探討，第三章係整理所蒐集到的各國情況，而於第四章中進行相關個案的訪談，最後在第五章中歸納出結論，並試著提出建議。深切期望我國除了致力於經濟之發展，亦能重視弱勢團體的需要，促進慢性精神病患者回歸社區，並進而使其能在社區中有尊嚴的生活和工作。

(内部障害系理学療法6,一般演題ポスター発表,理学療法の可能性,第41回日本理学療法学術大会)

本文データ差替え(2016/06/09) / 京都大学 / 0048 / 新制・課程博士 / 博士(人間・環境学) / 甲第19327号 / 人博第746号 / 新制||人||179(附属図書館) / 27||人博||746(吉田南総合図書館) / 32329 / 京都大学大学院人間・環境学研究科共生人間学専攻 / (主査)教授 ベッカー カール, 准教授 大倉 得史, 准教授 倉石 一郎, 教授 形井 秀一, / 学位規則第4条第1項該当 / Doctor of Human and Environmental Studies / Kyoto University / DFAM

抗がん剤による副作用が原因で外見が変化してしまったがん患者に美容施術を用いたサポートを行う実践を通して、美容施術が「対人的効用」や「心の健康」を生み出すに留まらず、がんになっても今まで通りの生活を営み、よりよく生きる(Well-being)を実現することができるのではないかという問いを、ウエルネスの視座を用いて実践研究を行った。加えて、理美容所がもつ地域内交流拠点としての社会的役割について見直し、ソーシャル・イノベーションの拠点として機能していく可能性についても論じた。 / 博士(ソーシャル・イノベーション) / Doctor of Philosophy in Social Innovation / 同志社大学 / Doshisha University

本研究之目的：一為探究年輕思覺失調症患者，於荒野臨界中如何形塑其此際體態；二為探討患者主要照顧者面對精神分裂體驗，從何接應患者，如何賦予其心理照顧意義。而後，以對元結構方式，探討患者及其照顧者雙方的心理經驗。研究者將患者「生命經驗」及其主要照顧者「照顧經驗」並置於現象場脈絡中，透過深度訪談，進行現象還原，以接近患者的內在經驗，反思照顧者照顧行動意義。方法上，本研究採取立意抽樣，以年輕思覺失調症患者與其主要照顧者作為研究對象，以配對方式進行資料蒐集，共三對受訪者（6位）接受訪談，患者部分為三位男性，而雙親照顧者部分為一位男性、兩位女性。資料蒐集後，以Henri Ellenberger之現象學分析方法（林耀盛，2002）分析。研究結果發現，年輕思覺失調症患者與其雙親主要照顧者共構之置身結構經驗的定向軌跡為：（1）超常隱匿於日常偽裝之下；（2）超常現身，即特異性經驗被看見，包含病者與雙親照顧者；（3）芻思心緒，反覆思索當前之事件；（4）經驗賦義，理解所發生的事，並給出位置，將其涵容於自我之中；（5）存有的流變：希望與憂懼心思。研究貢獻為在臨床心理實務上可能的幫助：可協助狀態逐漸穩定之個案進行經驗之整理，使其看見自己的狀態，而非僅僅使其擁有病識感、願意配合醫療處遇。而對雙親做為主要照顧者，可協助其釐清對於疾病狀態的未知，及自我照顧技藝的發展。礙於現實收案狀況，難以擴大取樣具異質性的思覺失調症患者，資料豐富度較為不足，為未來研究可改善之處。 / Purpose: This study is exploring (1) how the young schizophrenic patient perceived who he/she is in “the wilderness”; (2) how their caregivers faced with the schizophrenic experiences and constructed the meaning of caring; and (3) disclosing the patients and their caregiver’s mutual situated experiences by the meta-dyadic structure. Methods: Taking a qualitative approach grounded in phenomenological psychology, this study conducted in-depth interviews by which researchers strived to observe, analyze and understand, from their first-person perspective, how they live under such situation. The participants were recruited through purposive sampling. Three patient-caregiver dyads (three male schizophrenic patients with one male and two female caregivers) were interviewed. The analysis step is adopted by Henri Ellenberger’s existential-phenomenological method (Yaw-Sheng Lin, 2002). Results: Five over-arching themes emerged in the analysis on the transformation of experiences of suffering and caring. (1) Camouflaging the “extra-normal” in daily life. (2) “Extra-normal” is understood through the singularity in the daily life, including the patient and caregiver can “encounter” the unique experience. (3) Ruminative reflection about what happening? (4) Make sense of schizophrenic experiences through blurry the boundary between the normal and abnormal to integrate self into life orientation. (5) Existential experience as becoming process through the state of mind of “hope” and “Angst”. Conclusions: The outcome is implicated in clinical practice: (1) Return to young schizophrenic patients’ lifeworld beyond psychopathology comprehension to articulate the intersubjective understanding relationships. (2) Help caregiver to understand their uncanny situation and cultivate the caring ethics for self and the other. Limitation, future research agenda and suggestion are discussed and proposed.

研究目的：本研究使用共通信念模式，以瞭解第二型糖尿病患者持有的疾病表徵對自我照護行為的預測關係。過去的研究顯示，糖尿病患者的「控制」表徵能夠有效預測患者的自我照護行為和糖化血色素值；也就是，患者相信疾病能被控制的程度愈高，在自我照護行為的表現愈好，糖化血色素值愈低。但是，「結果」表徵與「情緒」表徵無法顯著一致的預測患者的自我照護行為。透過回顧與健康行為相關的理論發展與文獻，考量慢性疾病的自我調節歷程中，除了疾病表徵以外，還需要納入與自我意識有關的人格特質。為此，本研究目的有四:(1)先檢驗在台灣糖尿病患者的疾病表徵建構，是否與國外使用疾病共通信念模式的研究結果一致，有相同的因素結構。(2)檢定台灣第二型糖尿病患者，其持有的疾病表徵對自我照護行為與血糖控制的預測，是否與Harvey和Lawson(2009)的研究結果一致。(3)評估糖尿病患者的人格特質對自我照護行為與糖化血色素值的影響。(4)探索第二型糖尿病患者反芻反思特質，在疾病表徵影響自我照護行為上的調節效果。 研究方法：本研究以立意取樣的方式，邀請新竹某教學醫院門診的第二型糖尿病患者為受試。排除漏答與亂填者，共有142位符合資格的受試者；每位受試者皆需完成受試者同意書、背景資料、糖尿病自我照護量表、疾病表徵問卷與中文版反芻反思量表。根據研究目的，以階層回歸和羅吉斯回歸分析等統計方法進行假設考驗。 研究結果：(1)臺灣第二型糖尿病患者的疾病表徵結構與國外患者相似，共包含：「認同」、「病因」、「時間感急慢性」、「時間感循環性」、「結果」、「情緒」和「控制」表徵。(2)研究結果與Harvey和Lawson(2009)的研究結果一致，「控制」表徵可以顯著預測整體自我照護行為和糖化血色素值。(3)第二型糖尿病患者的反芻反思特質，無法單獨預測自我照護行為與糖化血色素值。(4) 第二型糖尿病患者的反芻反思特質會與病表徵產生交互作用，共同調節各種自我照護行為的表現。 結論：本研究資料與其他使用共通信念模式的研究資料一致，亦即控制表徵能預測自我照護行為和糖化血色素值。此外，本研究發現，不同自我照護行為會受到疾病表徵與反芻或反思特質的交互作用而影響。由於，增加自我照護行為的執行度，是目前糖尿病治療與衛教的首要目標。建議未來從事糖尿病照護的實務工作者，能提供疾病表徵與反芻反思特質的專業心理評估；以協助建立個別評估與個別介入的個別化治療方案，進而提高患者在自我照護行為的執行度、增加臨床治療的效果。 / Background and Aims. It is increasingly being used to understand and predict individuals' coping with and subsequent self-care of chronic illness is Leventhal and colleagues' the common sense model. This model postulates that it is the individual's illness representation is the proximal determinant of coping behavior. The role of personality in determining self-care behavior has been relatively ignored, possibly because of the lack of convergence in concepts and measures. Due to the lack of research in the area of interest, the present study attempt to resolve this issue. We investigated, (a) using subjects of Type-II diabetes in Taiwan, are the results of present study similar as others studies directed by common sense model to identify the factors of illness representation, (b) discussing the influences of illness representation to self-care behavior and glycemic control (HbA1c); like as Harvey and Lawson(2009)’s study, (c) assessing whether traits of normal personality are associated with variations in self-care behavior and glycemic control in patients with type 2 diabetes, (d) examining whether personality moderate the relationships between illness representations and self-care behavior. Methods. Patients were eligible if they had Type 2 diabetes, were aged 20 years or more at diagnosis. Before we collect data, a physician will invite patient to enter the study. Patient want to join this study, they be giving an informed consent and be asked to complete four questionnaires. A total 142 patients completed the demographic survey ( age, educational level, diabetes duration et al.), Diabetes Self-Care Scale, the Revised Illness Perception Questionnaire(IPQ-R), the Chinese version of Rumination- Reflection Questionnaire. Analysis were concluded using multiple regression analysis, logistic regression and so on. Results. The results revealed that: (1) as our hypothesis, the structures of the IPQ-R in type 2 diabetes in Taiwan were similar as other foreign studies directed by common sense model. (2) Control representation can induce main effect on self care behavior. Higher control representation was significantly positive associated with self care behavior, and it was significantly negative associated with HbA1c. (3) Self reflection and self rumination were inconsistently associated with self care behavior and HbA1c. (4) Personality moderated the relationships between illness representations and self-care behavior. Conclusions. This study supports the Common Sense Model (CSM) of illness representation when considering type 2 diabetes in Taiwan. Based on our results, we found personality traits may offer new insights in to variations in self-care in patients with type 2 diabetes undergoing standard management. Personality refers as self-reflection and self-rumination which moderated the relationships between illness representations and self-care behavior. Therefore, CSM could become the theoretical framework for psychological interventions in type 2 diabetes. Furthermore, according to the study result, we suggested the practitioners paying attention to the different interaction when representation and personality are together in diabetes’ each self-care behavior.

過去的研究顯示，反芻為憂鬱的危險因子，對憂鬱的發展與維持扮演重要的角色。然而，並不是所有反芻型態都會對個體帶來不利的影響。Treynor, Gonzalez與Nolen-Hoeksema（2003）從反芻反應風格量表中抽取出兩個因素結構：苦惱自責式反芻與深思反省式反芻。苦惱自責式反芻能正向預測憂鬱症狀，而深思反省式則是負向預測憂鬱症狀，為較具適應性的反芻型態。然而，過去文獻在深思反省式反芻上未能獲得一致的結論，可能與研究方法及受到苦惱自責式反芻污染的影響。為釐清深思反省式反芻對乳癌患者而言是否具適應性，本研究欲探討兩類反芻與憂鬱之關聯性，並在控制初始的憂鬱症狀後，檢驗兩類反芻對一年後憂鬱症狀的預測力，最後修正Takano與Tanno（2009）的模型探索兩類反芻之路徑關係如何影響憂鬱。 　　本研究以立意取樣的方式，追蹤283名乳癌患者，分別於受術後一年（T1）與手術後兩年（T2）進行問卷評量。每位參與者皆需完成知情同意書、背景資料、短版反芻反應風格量表、醫院憂鬱量表。根據研究目的，以相關分析、階層迴歸分析與路徑分析進行假設考驗。 　　研究結果顯示，苦惱自責式反芻、深思反省式反芻與憂鬱具有同時的正向關聯性。然而，在控制時間點一的憂鬱症狀後，深思反省式反芻則會預測一年後較低的憂鬱症狀，顯示其會帶來適應性的結果，與Treynor, Gonzalez與Nolen-Hoe ksema（2003）的研究結果一致。路徑分析結果發現，苦惱自責式反芻能預測一年後較低的深思反省式反芻與增加憂鬱症狀，但能同時增加深思反省式反芻；深思反省式反芻則能抑制苦惱自責式反芻，無法預測憂鬱症狀。 　　本研究發現與過去研究結果一致，在乳癌患者樣本上亦能發現兩類反芻具有不同的適應性功能，尤其深思反省式反芻可能透過抑制苦惱自責式反芻來降低一年後的憂鬱症狀，進一步支持反芻反應風格應區分為兩構念進行探討。建議在臨床上可針對乳癌患者進行反芻反應篩檢，以協助判斷患者在憂鬱症狀之預後，並針對高自責式反芻的患者進行心理介入。 / Literature review has shown that rumination is one of risk factors of depression. It plays a crucial rule of developing and sustaining depressive symptoms. However, the different types of rumination may not all lead to depression. Treynor, Gonzalez and Nolen-Hoeksema (2003) have extracted two factors from Ruminative Respon -ses Scale, brooding and reflective pondering. In their study, brooding positively pre -dicts depressive symptoms, but reflective pondering negatively predicts depressive symptoms, depicting that reflective pondering is an adaptive repetitive thinking. Yet, past studies haven’t reached a consensus on reflective pondering. It is probably due to research method and not taking the contamination of brooding into account. For clarifying the possible adaptive characteristic of reflective pondering, the present study examines the relationship between reflective pondering and depression. Furthermore, after controlling T1 depression, the present study explores the prediction of rumination to T2 depression. Last, we examine the predictive paths between brooding and reflective pondering to depression. 　　Patients were eligible if they have been diagnosed with breast cancer. We survey 283 patients after they had completed operation for a year, and follow-up at one year later. All patients complete the informed consent, the demographic survey, the short version of Ruminative Responses Scale, the Hospital Depression Scale. Analysis are conducted using Pearson correlation analysis, multiple regression analysis and path analysis. 　　The result revealed that brooding and reflective pondering are positively related to depression at T1. However, after controlling T1 depression, reflective pondering negatively predicted T2 depression. This result indicates that reflective pondering may be an adaptive form of rumination, matched the result of Treynor, Gonzalez and Nolen-Hoeksema (2003). In the result of path analysis, we also found brooding predicts less reflective pondering and more depression after one year, but it concurrently predicts more reflective pondering. On the other hand, reflective pondering predicts less brooding and has no significant impact on depression. The present study supports the finding of Treynor, Gonzalez and Nolen-Hoeksema (2003). In patients with breast cancer, reflective pondering negatively predicts depressive symptoms through reducing brooding. Brooding and reflective pondering are different forms of rumination, the former is more maladaptive and latter is adaptive. According to the study result, we suggest that clinicians screen for the high-brooder, and practice psychological interventions.

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