研究背景：乳癌患者常伴隨憂鬱症狀，而反芻是癌症患者憂鬱情形的重要預測因 數。過往研究指出苦惱自責式反芻增加憂鬱的效果得到較一致的結果，而深思反 省式反芻對於憂鬱影響的結果則不太一致。深思反省式反芻意在解決問題，過程 中患者採用不同因應策略可能對其憂鬱會有不同影響，但過去較少研究探討乳癌 患者的因應如何調節深思反省式反芻對患者憂鬱變化的影響。 研究目的：探究苦惱自責式反芻與深思反省式反芻如何影響乳癌患者的憂鬱，逃 避與趨近這兩種因應方式是否在深思反省式反芻影響憂鬱的過程中有調節作用。 研究方法：本研究採用長期追蹤之研究方法，對平均年齡為 48 歲的 359 位乳癌 患者，於手術後三個月、六個月、一年和兩年四個時間點，測量其苦惱自責式反 芻、深思反省式反芻，趨近、逃避等因應模式及憂鬱狀況後進行分析。為了探索 考個體內和個體間變項的影響，包含臨床背景資料對憂鬱的預測效果，研究擬採 用階層線性模型（HLM）之方法進行統計分析。 研究結果：苦惱自責式反芻正向預測乳癌患者憂鬱情形，深思反省式反芻對憂鬱 的預測效果則受到趨近因應的調節，趨近因應越高，深思反省式反芻越能負向預 測憂鬱情形。依此結果可知對於乳癌患者而言，苦惱自責式反芻為不適應的反芻 類型，會增加乳癌患者的憂鬱情形，而深思反省式反芻的適應性僅存在於更多使 用趨近因應的患者之中。 / Background: Depressive symptoms occur frequently with breast cancer. Rumination is a major risk factor of depression. Numerous research evidence shows that brooding, the maladaptive subtype of rumination, increases depression while the effect of reflective pondering, the other subtype, remain inconsistent. Individuals who reflective ponder mean to solve the problem they face, but there is little research to explore what role coping plays in the process that reflective pondering contribute to or eliminate depression. Purpose: To examine how two subtypes of rumination predict the depression of women with breast cancer, and whether the moderating effect of two different coping strategies, approach and avoidance, exists and how it works. Method: Longitudinal data of rumination, coping, and depression at Time 1 (3 months after surgery), Time 2 (6 months after surgery), Time 3 (1year after surgery), and Time 4 (2 years after surgery) among 359 women with breast cancer whose mean age was 48 was collected to explore the prediction of rumination and the moderating effect of coping. To address the effect of both with- and between- subject variables including background materials and disease-related information, HLM is adopted as the analysis method. Results: Brooding predicts the increase of depressive symptoms and acts as the maladaptive subtype of rumination. In addition, reflective pondering’ prediction to decreased depression only appears with the interaction of approach coping, which means that patients who reflective ponder more and take more approach coping at the meanwhile will experience more recovery from the depressive symptoms.

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.

根據Koster、De Lissnyder、Derakshan及De Raedt（2011）的注意力轉移困難假說，憂鬱者因注意力控制能力受損，而難以從負向訊息中轉移注意力，進而引發反芻，並再度強化憂鬱症狀。雖然反芻可再細分為深思反省與苦惱自責式反芻，但Koster等人未探究注意力轉移困難對苦惱自責式反芻的影響。此外，過往注意力訓練研究作業眾多且效果不一，又偏重改善個體注意力投入以減緩憂鬱。然而，卻鮮少探討注意力訓練對注意力轉移困難的介入，能否改善個體的苦惱自責式反芻程度。因此，本研究將同時探討注意力訓練能否改變高苦惱自責式反芻者對負向訊息的注意力偏誤（含注意力投入與轉移困難），進而降低苦惱自責式反芻程度。本研究以點偵測作業為注意力訓練作業，將高、低苦惱自責式反芻者隨機分派至注意力訓練組或注意力訓練控制組，接受為期兩週、共四次的注意力訓練，並於前、後測階段注意力測量作業中，檢驗對負向訊息的注意力偏誤與三階段中苦惱自責式反芻程度。本研究結果發現高苦惱自責式反芻者對負向訊息無明顯注意力偏誤，注意力訓練作業對高苦惱自責式反芻者的注意力歷程未有明顯影響，乃至苦惱自責式反芻程度的時序變化與接受注意力訓練與否無明顯關聯。本研究結果不支持原先假設、注意力困難假說及過去研究結果。然而，過往學者多強調個體高度負向認知與憂鬱情緒對注意力偏誤的影響，故本研究事後同時納入憂鬱與苦惱自責式反芻程度，欲探討憂鬱苦惱自責式反芻者對負向訊息有無注意力偏誤，乃至注意力訓練對憂鬱苦惱自責式反芻者注意力偏誤的訓練效果。本研究結果僅發現在修正版Posner作業中，憂鬱苦惱自責式反芻者更容易將注意力從負向訊息中轉移開來；在點偵測作業中，未有組間效果；在注意力訓練中，未有訓練效果。最後，本研究將於討論中，探討研究結果的可能原因，並提出本研究限制與未來研究上的建議。 / According to the impaired disengagement hypothesis (Koster, De Lissnyder, Derakshan, & De Raedt, 2011), the dysphoric that are difficult to disengage from negative stimuli due to low attentional control tend to ruminate, and then even worsen their depressive symptoms. Actually, rumination can be differentiated into two components: reflective pondering and brooding, but the core tenet of impaired disengagement hypothesis only puts the emphasis on rumination rather than brooding. Besides, there are many studies investigating the attention-training effects on depressive symptoms rather than rumination. To date, no studies even have investigated the training effects on impaired disengagement and brooding. Therefore, we aimed to examine the effects of attention training on attention bias toward negative stimuli, impaired disengagement from negative stimuli and brooding level in brooders. We investigated the training effect in brooding and non-psychiatric control participants via dot-probe task. During a two-week period, all of the participants were randomly assigned to complete 4 sessions of either attention training or no training. Also, participants completed two attentional tasks examined attention bias at baseline and post-training, and self-reported questionnaires of brooding and depressive symptoms at baseline, post-training, and follow-up. Overall, results indicate that brooders didn’t show attention bias to negative stimuli. Also, no beneficial effects of attention training on attention bias and brooding level were found in brooders. The previous hypothesis, impaired disengagement hypothesis and studies in the past were not supported. However, many cognitive models of depression have postulated that individuals with high levels of negative cognition and depressive affect tend to maintain their attention toward negative information. Therefore, we took levels of depression and brooding into account, and aimed to examine the effects of attention training on both attention bias toward negative stimuli and impaired disengagement from negative stimuli in depressive brooders. Results indicate that depressive brooders tend to disengage from negative stimuli in modified Posner task. No other findings in dot-probe task and attention-training task. Implications of these findings in depressive brooders are discussed and directions for future research are advanced.