本文關(guān)鍵詞：基于中醫(yī)學理論的主觀性失眠評定問卷的研制與初步應(yīng)用　出處：《廣州中醫(yī)藥大學》2017年博士論文　論文類型：學位論文

  更多相關(guān)文章： 非器質(zhì)性失眠 中醫(yī)心理學 主觀性失眠 癥狀 非理性思維

【摘要】：目的:1.編制具有中國文化特色、有助于了解失眠者身心現(xiàn)狀的臨床實用性的失眠評定問卷系統(tǒng)梳理傳統(tǒng)中醫(yī)學與現(xiàn)代醫(yī)學中睡眠理論的主要觀點與歷史發(fā)展,把握中醫(yī)學和現(xiàn)代醫(yī)學對睡眠生理、失眠病因病機以及治法用藥的認識,挖掘中醫(yī)心理學與現(xiàn)代心理學中對睡眠心理相關(guān)內(nèi)容的研究,分析現(xiàn)有的睡眠評估工具的特點和不足,建構(gòu)主觀性失眠評定問卷的基本結(jié)構(gòu)。以儒、釋、道家文化為主的中國文化影響著國人生活的方方面面,尤其是心理方面。本問卷在編制之初便充分考慮到中國特色文化對失眠者的影響,在與失眠者的訪談中也證實了這種文化影響的存在,特別是"家文化"和"夢文化"在失眠的發(fā)生發(fā)展過程中有著特殊的意義。了解失眠者的身心現(xiàn)狀,可為下一步的治療提供參考依據(jù)。因此,建立一個能反映中國特色文化對失眠者心理影響的、有助于了解失眠者身心現(xiàn)狀的評定問卷無疑會提高問卷的臨床實用性。本問卷在某些具體條目中體現(xiàn)了這些文化特質(zhì),失眠者在填寫問卷的同時也是對自己心理的了解過程,本問卷不僅僅是作為一個測量工具,填寫過程本身也是對失眠者心理干預的開始。2.編制一個能有助于臨床快速鑒別主觀性失眠的問卷主觀性失眠的典型特征是失眠者主訴有嚴重失眠但缺乏客觀證據(jù)的支持,就是失眠者的主觀失眠評估高于客觀評估。臨床上失眠的診斷主要依靠的便是失眠者的主訴,因此較難區(qū)分主觀性失眠;現(xiàn)有的以自評方式評價的睡眠量表同樣無法進行區(qū)分。這樣的后果是主觀性失眠者得不到有針對性地治療,這便是主觀性失眠難治的根本原因所在。編制一個能快速鑒別主觀性失眠的問卷符合臨床的實際需要。3.運用主觀性失眠評定問卷,探索該問卷的適用人群并制定問卷的評價標準用本研究問卷對非器質(zhì)性失眠者進行調(diào)查,了解非器質(zhì)性失眠者的心理現(xiàn)狀,分析不同人群在非器質(zhì)性失眠者評定問卷上的分布特征,探討影響這種分布可能的因素,如性別、年齡、職業(yè)、經(jīng)濟狀況、受教育程度等;同時還選取了部分睡眠正常且無熬夜習慣的健康人進行主觀性失眠評定問卷的測評,比較失眠者與健康人問卷評定結(jié)果。通過這些分析比較,制定問卷的評價標準,進一步分析探索本問卷的適用人群。方法:1.文獻研究法本研究利用利用學校圖書館和網(wǎng)站,通過CNKI數(shù)據(jù)庫、萬方資源數(shù)據(jù)庫、維普期刊數(shù)據(jù)庫、PubMed、SCIE等電子資源網(wǎng)站,系統(tǒng)全面地對與睡眠和失眠相關(guān)的量表或問卷文獻研究資料進行查找收集,了解失眠的研究現(xiàn)狀,認真學習失眠的研究方法,分析了解失眠有關(guān)量表或問卷的編制方法及其特點。通過對《睡眠障礙國際分類第3版》、《精神障礙診斷和統(tǒng)計手冊第5版》、《ICD-10精神與行為障礙分類》和《中國精神障礙分類及診斷標準第3版》這幾個國內(nèi)外關(guān)于失眠的診斷和分類標準進行分析研究,厘清非器質(zhì)性失眠癥的概念內(nèi)涵。本研究還參考《行為醫(yī)學量表手冊》、《心理衛(wèi)生評定量表手冊》等心理測量工具書中睡眠相關(guān)量表的內(nèi)容,以及《生理學》、《中醫(yī)心理學》、《臨床心理學》、《咨詢心理學》、《中醫(yī)內(nèi)科學》等專業(yè)書籍中對睡眠生理和失眠病因病機以及診治方面的內(nèi)容,總結(jié)出較為有代表性的、與失眠者心理方面關(guān)系密切的內(nèi)容,為建立主觀性失眠評定問卷初選條目池作準備。2.訪談法本研究采用正式訪談的形式對非器質(zhì)性失眠者及親屬進行面對面的訪談。每次訪談時間為30-60分鐘。觀察并記錄每一名非器質(zhì)性失眠者的精神、面容以及情緒狀態(tài),了解他們持有的與失眠有關(guān)的思維內(nèi)容及行為反應(yīng)。考察的時間點為近一個月。訪談內(nèi)容按預先制定的提綱進行記錄,內(nèi)容包括睡眠時間、失眠相關(guān)癥狀與體征、與失眠相關(guān)的觀念和行為、生活現(xiàn)狀等。通過對訪談所獲得資料的綜合分析歸納,提取出可納入問卷初選條目池的條目。3.Delphi法基于前期文獻研究和對非器質(zhì)性失眠者及親屬的正式訪談,建立主觀性失眠評定問卷初選條目池,并結(jié)合中醫(yī)心理學和現(xiàn)代心理學理論知識建構(gòu)出問卷的基本維度。邀請9位兼具醫(yī)學、中醫(yī)學和心理學背景的具有10年以上臨床和心理從業(yè)經(jīng)驗的專家,對所建立的問卷初選條目池及理論構(gòu)想的維度進行2輪Delphi法專家咨詢,對各條目和維度的重要性、可行性進行評判,并編寫權(quán)重,可對條目或維度提出具體的修改意見或建議增添某條目。設(shè)立修改及增刪標準。每輪結(jié)束后對調(diào)查的結(jié)果進行統(tǒng)計分析,根據(jù)分析的結(jié)果,對達到修改或增刪標準的條目進行相應(yīng)的修改訂正,最終確定初步問卷的維度和總條目,確立問卷的作答形式,計分規(guī)則等,編制主觀性失眠評定初步問卷。4.問卷調(diào)查法用經(jīng)過Delphi法修訂后編制的主觀性失眠評定初步問卷,對一定數(shù)量的符合納入標準的廣州中醫(yī)藥大學第一附屬醫(yī)院心理和腦病門診中的非器質(zhì)性失眠者進行初步調(diào)查。在進行調(diào)查的過程中進一步確定問卷的作答形式、計分規(guī)則以及作答時間等項目或進行修改,形成正式問卷。隨后對293例失眠者用主觀性失眠評定正式問卷進行測評,進行信度和效度檢驗,最終確定問卷。最后應(yīng)用主觀性失眠評定問卷對337例失眠者和87例健康人進行測評,并且應(yīng)用匹茲堡睡眠質(zhì)量指數(shù)量表對337例失眠者進行測評。同時對30例主觀性失眠者進行體動記錄儀測量。5.數(shù)理統(tǒng)計方法本研究采用Excel 2010版本進行數(shù)據(jù)的雙錄入和整理,采用20.0版本的社會科學統(tǒng)計軟件包,建立數(shù)據(jù)庫進行統(tǒng)計分析。在Delphi法中,用專家積極系數(shù)、專家權(quán)威程度系數(shù)、專家意見協(xié)調(diào)系數(shù)以及專家意見變異系數(shù)來衡量專家咨詢的可靠性和權(quán)威性程度,主要是采用描述統(tǒng)計、均值比較以及多個相關(guān)樣本的非參數(shù)檢驗來進行統(tǒng)計分析。對問卷調(diào)查法所獲得的問卷數(shù)據(jù)資料,用描述統(tǒng)計、均值比較、項目分析、方差分析相關(guān)分析等探索變量間的關(guān)系,并檢驗問卷的內(nèi)容效度;用配對樣本t檢驗、相關(guān)分析法評價問卷重測信度;用Cronbach' α系數(shù)和相關(guān)分析法進行問卷的內(nèi)在信度分析;用探索性因素分析、相關(guān)分析法等檢驗問卷的結(jié)構(gòu)效度,并篩選條目并確定問卷的理論框架結(jié)構(gòu)及理論維度;用配對樣本t檢驗及相關(guān)分析檢驗問卷的效標效度。成果:1.系統(tǒng)梳理了中醫(yī)和現(xiàn)代醫(yī)學關(guān)于睡眠和失眠認識的歷史發(fā)展本研究通過中醫(yī)經(jīng)典文獻研究,系統(tǒng)梳理了從《黃帝內(nèi)經(jīng)》到現(xiàn)代中醫(yī)學對睡眠生理及失眠病因病機、治則治法以及理法方藥的相關(guān)文獻記載。睡眠總的機制在于陰陽的盛衰變化,而氣血盛衰、臟腑功能、邪氣等對睡眠有影響。在此基礎(chǔ)上,分析失眠的病機為陽盛陰虛,而氣血衰少、臟腑功能失調(diào)、外感或內(nèi)傷邪氣、因虛等也可導致失眠。而其總的治則為調(diào)整臟腑氣血陰陽。而治療方面則采用了辨證論治與針灸、推拿等多種方式。中醫(yī)心理學則在此基礎(chǔ)上提出了情志病變與失眠互為因果的觀點,強調(diào)了心理治療在失眠治療中的重要性,并提出了一系列具有中醫(yī)特色的心理治療方法�，F(xiàn)代醫(yī)學對于對失眠的認識也經(jīng)歷了從生物醫(yī)學到心身醫(yī)學的發(fā)展轉(zhuǎn)變,從最初的單純藥物治療到現(xiàn)在的藥物與心理的綜合治療,心理因素在失眠發(fā)生發(fā)展中的作用日益得到醫(yī)患雙方的重視。2.編制了具有中國文化特色的能快速鑒別主客觀失眠的主觀性失眠評定問卷本研究遵循心理學測量問卷的編制原則,參考現(xiàn)代心理測量問卷規(guī)范的編制程序與方法,構(gòu)建主觀性失眠評定問卷的理論框架和癥狀與體征、認知、行為、情緒感受、社會功能五個維度,編制了主觀性失眠評定問卷,確定由26個條目構(gòu)成的正式問卷。本研究對主觀性失眠評定問卷的可行性、信度和效度進行了檢驗。問卷的接受性和回收率均為100%,其平均完成時間為4.73±2.18分鐘,超過90%的失眠者完成本問卷的時間為3-8分鐘,本問卷有較好的臨床可行性;其重測信度在0.9以上,Crobach'α系數(shù)值和分半信度系數(shù)值均大于0.7,說明本問卷有良好的信度;該問卷經(jīng)內(nèi)部一致性檢驗,除條目2與問卷得分相關(guān)系數(shù)略低于0.20外,其余條目與問卷得分的相關(guān)系數(shù)在0.222-0.570之間,各維度與總問卷的相關(guān)系數(shù)在0.488-0.639之間,各條目與其所屬維度得分的相關(guān)系數(shù)在0.317-0.917之間,而它們與其它維度得分的相關(guān)系數(shù)值均小于與其所屬維度得分的相關(guān)系數(shù)值,P值均小于0.01,呈顯著相關(guān),說明本問卷有較好的內(nèi)容效度。本問卷與匹茲堡睡眠質(zhì)量指數(shù)量表得分的相關(guān)系數(shù)r值大于0.8,表明本問卷有較好的校標關(guān)聯(lián)效度。探索性因素分析提取的公因子基本對應(yīng)理論構(gòu)想的情緒感受、癥狀與體征、行為、認知和社會功能五維度,說明本問卷具有較好的結(jié)構(gòu)效度。本問卷的效應(yīng)尺度為2.84,本問卷有良好的反應(yīng)度。本問卷的客觀失眠指數(shù)可以區(qū)分主客觀失眠,低于3分為主觀性失眠,與體動記錄儀監(jiān)測結(jié)果的相關(guān)系數(shù)大于0.7,呈顯著相關(guān),本問卷可以快速鑒別主客觀性失眠。結(jié)論:1.睡眠受到多種因素的影響,社會心理因素在失眠的發(fā)生發(fā)展以及轉(zhuǎn)歸中起著十分重要的作用。對于非器質(zhì)性失眠者,社會心理因素更是主要的致病因素。2.研制的主觀性失眠評定問卷經(jīng)各項統(tǒng)計學檢驗以及與匹茲堡睡眠質(zhì)量指數(shù)量表比較,顯示本問卷具有較好的信度和效度以及良好的臨床可行性,為臨床了解非器質(zhì)性失眠者的非理性思維和行為反應(yīng)模式提供了具有中國文化特色和符合中國人語言習慣的測量工具。3.研制的主觀性失眠評定問卷可用于快速鑒別主觀性失眠。4.運用本問卷對非器質(zhì)性失眠者進行調(diào)查,結(jié)果顯示心理因素與失眠者病情的發(fā)展關(guān)系密切。而隨著失眠病情的好轉(zhuǎn),問卷得分明顯下降。將主觀性失眠評定問卷與匹茲堡睡眠質(zhì)量指數(shù)量表評定結(jié)果進行比較,兩者有很好的相關(guān)性,驗證了本問卷測量的可靠性,能為臨床上影響非器質(zhì)性失眠者病情的心理因素方面的評定提供方便、快捷的測評方式。
[Abstract]:Objective: to prepare 1. has China culture characteristic, is helpful to understand the physical and mental status of insomnia insomnia clinical utility assessment questionnaire system combing traditional Chinese medicine and the main ideas of sleep theory in modern medicine and the development of history, grasp of traditional Chinese medicine and Western Medicine on sleep physiology, etiology and pathogenesis and treatment of insomnia medication, study mining on sleep related psychological content of TCM psychology and modern psychology, analysis of the characteristics of the existing sleep assessment tools and the lack of basic structure questionnaire. Subjective insomnia with Confucianism, Buddhism, Taoism culture based Chinese culture affects people in all aspects of life, especially in the questionnaire and psychological aspects. At the beginning of the preparation of fully considering the influence of Chinese culture for insomnia, and insomnia in the interview also confirmed the existence of this cultural influence, especially the "home culture" And "dream culture" in the process of development of insomnia has a special significance. And to understand the status quo of insomnia, it can provide a reference for the next treatment. Therefore, the establishment of a Chinese culture can reflect the influence of insomnia psychological questionnaire, helps to understand the status of body and mind insomnia will improve the clinical utility of the questionnaire. The questionnaire reflects the cultural characteristics in some specific items in the questionnaire, insomnia is also the process of understanding their psychological, not only is the questionnaire as a measurement tool, fill in the process itself is insomnia complained of severe insomnia but lack of objective evidence support to start the preparation of a typical feature of.2. can contribute to the rapid identification of clinical subjective insomnia questionnaire subjective insomnia insomnia psychological intervention, insomnia is the subjective evaluation on high insomnia Objective evaluation. The clinical diagnosis of insomnia mainly depends on is complained of insomnia, so it is difficult to distinguish subjective insomnia; prior to sleep scale self rating evaluation also cannot distinguish. The consequences of this is the subjective insomnia not targeted treatment, this is the fundamental reason of subjectivity insomnia difficult. Preparation of a rapid identification of subjective insomnia questionnaire with subjective insomnia questionnaire using the actual needs of clinical.3., explore the suitable crowd questionnaire and making questionnaire evaluation criteria used in this study were of non organic insomnia were investigated, the psychological status of non organic insomnia, analysis of different population distribution in non organic insomnia assessment questionnaire, and to explore the influencing factors of the distribution such as gender, age, occupation, economic status, education level; at the same time The evaluation also selected healthy people and no normal part of the sleep habits of late subjective insomnia insomnia questionnaire, compared with healthy people. The results were assessed by the analysis and comparison, questionnaire evaluation standard, further analysis of the questionnaire to explore suitable crowd. Methods: 1. literature research this research by using the school library and website according to the CNKI database, Wanfang database, VIP database, PubMed, SCIE and other electronic resources website, and systematically on sleep and insomnia related scale questionnaire or literature research data were collected to find, understand the research status of insomnia, insomnia seriously study and research methods, analyze the compilation method about insomnia scale or questionnaire and characteristics. Based on the international classification of sleep disorders third edition of < >, < diagnostic and Statistical Manual of mental disorders fifth edition of < ICD-10 >, spirit and behavior Analysis on the classification and diagnostic criteria of obstacle classification > and < China > on diagnosis of mental disorders third edition of insomnia a few at home and abroad and classification standards, to clarify the connotation of the concept of non organic insomnia. This study also reference behavior scale manual < >, < sleep rating scale for mental health and psychological measurement > the tool book scale, physiology and < >, < > < TCM psychology, clinical psychology > >, < < the counseling psychology, sleep physiology and disease diagnosis and treatment of insomnia and other professional books content > in Chinese medicine, summed up the representative, and insomnia the psychological aspect is closely related to the content, prepare.2. interviews this research using formal interviews in the form of face-to-face interviews with non organic insomnia and relatives for the establishment of subjective insomnia questionnaire of the primary item pool. Each interview time is 30 -60 minutes. Observe and record every non organic insomnia spirit, face and emotion, understanding and thinking about the content of insomnia and behavioral responses they hold. The time for nearly a month. The interviews were recorded according to the pre established outline, including sleep, insomnia the symptoms and signs associated with insomnia, attitudes and behavior, life status. Through the comprehensive analysis of the data obtained by interviews summarized, extracted items can be included in the.3.Delphi questionnaire the primary entry pool of previous literature and Research on non organic insomnia and the relatives of the formal interview based on a questionnaire of primary subjective insomnia the item pool, and combined with TCM psychology and modern psychology theory to construct the basic knowledge questionnaire. 9 invited both medicine and traditional Chinese medicine and psychology background with more than 10 years of clinical and Experts experience, the primary theory and questionnaire item pool of the dimensions of the 2 round of the Delphi method of expert consultation, the importance of each item and dimension, evaluate the feasibility, and the preparation of the weight, can put forward specific suggestions for the revision of entries or dimensions or suggestions to add some items. The establishment of modifications and additions standard. After the end of each round of the survey results for statistical analysis, according to the results of the analysis, modify the corresponding correction to modify or add or delete the standard items, and ultimately determine the initial dimension of the questionnaire and total entries, establish the questionnaire answer form, scoring rules, making assessment of subjective insomnia questionnaire subjective insomnia questionnaire assessment after the revised Delphi method for.4. questionnaire, for a certain number of meet the inclusion criteria of the First Affiliated Hospital of Guangzhou University of Chinese Medicine psychology and brain disease clinic Preliminary investigation of non organic insomnia. To further determine the answer in the form of a questionnaire to investigate the process of scoring rules and answer time project or modify the formal questionnaire. Then in 293 cases of insomnia with subjective insomnia assessment formal questionnaire evaluation, reliability and validity test, and ultimately determine the questionnaire the application of subjective insomnia. Finally assessment questionnaire was used to test 337 cases of insomnia and 87 healthy people, and the application of Pittsburgh sleep quality index scale were assessed in 337 cases of insomnia. At the same time, 30 cases of subjective insomnia were actigraphy measurement.5. statistical methods this study used Excel 2010 version of the double input data and finishing, using the statistical package for social science 20 version of the package, statistical analysis database. In the Delphi, with a positive coefficient of experts, expert Quan Weicheng The degree of reliability coefficient, and the authority of the expert opinion coordination coefficient and the variation coefficient of expert opinion to measure expert consultation, mainly adopts descriptive statistics, mean comparison and non parametric test a number of related samples for statistical analysis. The questionnaire data obtained by questionnaire, using descriptive statistics, mean comparison, analysis of the project the analysis of variance, correlation analysis to explore the relationship between the variables, and test the content validity of the questionnaire; using paired samples t test, correlation analysis evaluation questionnaire test-retest reliability; analysis of internal reliability questionnaire with Cronbach'coefficient and correlation analysis method; by the exploratory factor analysis, structure validity analysis test questionnaire the screening items and determining the theoretical framework and theoretical dimensions questionnaire; using paired samples t test and correlation analysis to test the criterion validity of the questionnaire. Results: 1. system comb Institute of traditional Chinese medicine and modern medicine on sleep and insomnia awareness of historical development through the study on the Chinese classical literature, systematically from "Huangdi Neijing > to modern Chinese medicine on sleep physiology and insomnia, etiology and pathogenesis, therapeutic methods and relevant literature prescription records. The mechanism is the rise and fall of total sleep the changes of yin and Yang and Qi and blood, viscera function, evil have effects on sleep. On this basis, analysis of the pathogenesis of insomnia is Yang deficiency, and blood decline less dysfunctional organs, external or internal injuries caused by deficiency of evil, can also lead to insomnia. But the general rule is to adjust the blood and viscera the treatment of yin and Yang. It uses TCM and acupuncture, massage and other methods. The psychology of TCM is put forward on the basis of emotional disease and insomnia reciprocal causation perspective, emphasizes the importance of psychological treatment for insomnia, and A series of characteristics of TCM psychological therapy. Modern medicine for understanding of insomnia has also experienced the development of psychosomatic medicine to biomedical transformation, from the initial simple drug therapy to the comprehensive treatment of current drug and psychological, psychological factors of insomnia in the role in the occurrence and development of both doctors and patients increasingly attention to.2. system the Chinese has the cultural characteristics of the subjective insomnia questionnaire can quickly identify subjective insomnia this study followed the psychology questionnaire compilation principles, reference to modern psychology instruments to regulate the establishment procedures and methods, construction of subjective questionnaire and the theoretical framework of insomnia symptoms and signs, cognition, behavior, emotion, social function of five dimensions preparation of the questionnaire, subjective insomnia, determine the formal questionnaire consists of 26 items. The research on subjective insomnia questionnaire The feasibility, reliability and validity of the questionnaire. Acceptance and recovery rate was 100%, the average completion time is 4.73 + 2.18 minutes, more than 90% of the insomnia completed the questionnaire for 3-8 minutes, the questionnaire has a good clinical feasibility; the test-retest reliability in 0.9, numerical Crobach'alpha and split half reliability system are greater than 0.7, the questionnaire has good reliability; through the questionnaire internal consistency test, except for item 2 related questionnaire score coefficient was slightly lower than 0.20, the remaining items and the questionnaire score correlation coefficient between 0.222-0.570, each dimension and the total questionnaire correlation coefficient between 0.488-0.639 and the items and their respective scores, the correlation coefficient between 0.317-0.917, and their correlation coefficient with other dimension scores correlation coefficients were less than their respective scores, P values were less than 0.01, were significantly correlated That shows good content validity of the questionnaire. The questionnaire of Pittsburgh and the correlation coefficient of R sleep quality index score greater than 0.8, it shows that the questionnaire has good criterion related validity. Exploratory factor analysis theory of common factors extracted corresponding basic emotions, symptoms and signs, cognition and behavior. The social function of five dimensions, the questionnaire has good construct validity. The effect of the scale of the questionnaire was 2.84, the questionnaire has a good response. The objective index of insomnia this questionnaire can distinguish between subjective and objective insomnia, less than 3 is divided into subjective insomnia, and the correlation coefficient of body dynamic monitoring results of recorder is greater than 0.7, showed a significant correlation this questionnaire, can quickly identify subjective insomnia. Conclusion: 1. sleep is affected by many factors, the role of social psychological factors are very important in the occurrence and development of insomnia and outcomes of plays for non. Insomnia, social and psychological factors is the main pathogenic factors of.2. developed subjective insomnia questionnaire by various statistical tests and Pittsburgh sleep quality index scale, the questionnaire has good reliability and validity and clinical feasibility of good, provides China cultural characteristics and meet the Chinese language habits.3. measurement tool developed questionnaire of subjective insomnia can be used for rapid identification of subjective insomnia.4. with the use of non organic insomnia survey questionnaire for the non rational thinking and behavior mode of clinical understanding of nonorganic insomnia,.

【學位授予單位】：廣州中醫(yī)藥大學
【學位級別】：博士
【學位授予年份】：2017
【分類號】：R256.23

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