基于中医学理论的主观性失眠评定问卷的研制与初步应用

发布时间：2018-01-15 20:18

本文关键词：基于中医学理论的主观性失眠评定问卷的研制与初步应用　出处：《广州中医药大学》2017年博士论文　论文类型：学位论文

【摘要】：目的:1.编制具有中国文化特色、有助于了解失眠者身心现状的临床实用性的失眠评定问卷系统梳理传统中医学与现代医学中睡眠理论的主要观点与历史发展,把握中医学和现代医学对睡眠生理、失眠病因病机以及治法用药的认识,挖掘中医心理学与现代心理学中对睡眠心理相关内容的研究,分析现有的睡眠评估工具的特点和不足,建构主观性失眠评定问卷的基本结构。以儒、释、道家文化为主的中国文化影响着国人生活的方方面面,尤其是心理方面。本问卷在编制之初便充分考虑到中国特色文化对失眠者的影响,在与失眠者的访谈中也证实了这种文化影响的存在,特别是"家文化"和"梦文化"在失眠的发生发展过程中有着特殊的意义。了解失眠者的身心现状,可为下一步的治疗提供参考依据。因此,建立一个能反映中国特色文化对失眠者心理影响的、有助于了解失眠者身心现状的评定问卷无疑会提高问卷的临床实用性。本问卷在某些具体条目中体现了这些文化特质,失眠者在填写问卷的同时也是对自己心理的了解过程,本问卷不仅仅是作为一个测量工具,填写过程本身也是对失眠者心理干预的开始。2.编制一个能有助于临床快速鉴别主观性失眠的问卷主观性失眠的典型特征是失眠者主诉有严重失眠但缺乏客观证据的支持,就是失眠者的主观失眠评估高于客观评估。临床上失眠的诊断主要依靠的便是失眠者的主诉,因此较难区分主观性失眠;现有的以自评方式评价的睡眠量表同样无法进行区分。这样的后果是主观性失眠者得不到有针对性地治疗,这便是主观性失眠难治的根本原因所在。编制一个能快速鉴别主观性失眠的问卷符合临床的实际需要。3.运用主观性失眠评定问卷,探索该问卷的适用人群并制定问卷的评价标准用本研究问卷对非器质性失眠者进行调查,了解非器质性失眠者的心理现状,分析不同人群在非器质性失眠者评定问卷上的分布特征,探讨影响这种分布可能的因素,如性别、年龄、职业、经济状况、受教育程度等;同时还选取了部分睡眠正常且无熬夜习惯的健康人进行主观性失眠评定问卷的测评,比较失眠者与健康人问卷评定结果。通过这些分析比较,制定问卷的评价标准,进一步分析探索本问卷的适用人群。方法:1.文献研究法本研究利用利用学校图书馆和网站,通过CNKI数据库、万方资源数据库、维普期刊数据库、PubMed、SCIE等电子资源网站,系统全面地对与睡眠和失眠相关的量表或问卷文献研究资料进行查找收集,了解失眠的研究现状,认真学习失眠的研究方法,分析了解失眠有关量表或问卷的编制方法及其特点。通过对《睡眠障碍国际分类第3版》、《精神障碍诊断和统计手册第5版》、《ICD-10精神与行为障碍分类》和《中国精神障碍分类及诊断标准第3版》这几个国内外关于失眠的诊断和分类标准进行分析研究,厘清非器质性失眠症的概念内涵。本研究还参考《行为医学量表手册》、《心理卫生评定量表手册》等心理测量工具书中睡眠相关量表的内容,以及《生理学》、《中医心理学》、《临床心理学》、《咨询心理学》、《中医内科学》等专业书籍中对睡眠生理和失眠病因病机以及诊治方面的内容,总结出较为有代表性的、与失眠者心理方面关系密切的内容,为建立主观性失眠评定问卷初选条目池作准备。2.访谈法本研究采用正式访谈的形式对非器质性失眠者及亲属进行面对面的访谈。每次访谈时间为30-60分钟。观察并记录每一名非器质性失眠者的精神、面容以及情绪状态,了解他们持有的与失眠有关的思维内容及行为反应。考察的时间点为近一个月。访谈内容按预先制定的提纲进行记录,内容包括睡眠时间、失眠相关症状与体征、与失眠相关的观念和行为、生活现状等。通过对访谈所获得资料的综合分析归纳,提取出可纳入问卷初选条目池的条目。3.Delphi法基于前期文献研究和对非器质性失眠者及亲属的正式访谈,建立主观性失眠评定问卷初选条目池,并结合中医心理学和现代心理学理论知识建构出问卷的基本维度。邀请9位兼具医学、中医学和心理学背景的具有10年以上临床和心理从业经验的专家,对所建立的问卷初选条目池及理论构想的维度进行2轮Delphi法专家咨询,对各条目和维度的重要性、可行性进行评判,并编写权重,可对条目或维度提出具体的修改意见或建议增添某条目。设立修改及增删标准。每轮结束后对调查的结果进行统计分析,根据分析的结果,对达到修改或增删标准的条目进行相应的修改订正,最终确定初步问卷的维度和总条目,确立问卷的作答形式,计分规则等,编制主观性失眠评定初步问卷。4.问卷调查法用经过Delphi法修订后编制的主观性失眠评定初步问卷,对一定数量的符合纳入标准的广州中医药大学第一附属医院心理和脑病门诊中的非器质性失眠者进行初步调查。在进行调查的过程中进一步确定问卷的作答形式、计分规则以及作答时间等项目或进行修改,形成正式问卷。随后对293例失眠者用主观性失眠评定正式问卷进行测评,进行信度和效度检验,最终确定问卷。最后应用主观性失眠评定问卷对337例失眠者和87例健康人进行测评,并且应用匹兹堡睡眠质量指数量表对337例失眠者进行测评。同时对30例主观性失眠者进行体动记录仪测量。5.数理统计方法本研究采用Excel 2010版本进行数据的双录入和整理,采用20.0版本的社会科学统计软件包,建立数据库进行统计分析。在Delphi法中,用专家积极系数、专家权威程度系数、专家意见协调系数以及专家意见变异系数来衡量专家咨询的可靠性和权威性程度,主要是采用描述统计、均值比较以及多个相关样本的非参数检验来进行统计分析。对问卷调查法所获得的问卷数据资料,用描述统计、均值比较、项目分析、方差分析相关分析等探索变量间的关系,并检验问卷的内容效度;用配对样本t检验、相关分析法评价问卷重测信度;用Cronbach' α系数和相关分析法进行问卷的内在信度分析;用探索性因素分析、相关分析法等检验问卷的结构效度,并筛选条目并确定问卷的理论框架结构及理论维度;用配对样本t检验及相关分析检验问卷的效标效度。成果:1.系统梳理了中医和现代医学关于睡眠和失眠认识的历史发展本研究通过中医经典文献研究,系统梳理了从《黄帝内经》到现代中医学对睡眠生理及失眠病因病机、治则治法以及理法方药的相关文献记载。睡眠总的机制在于阴阳的盛衰变化,而气血盛衰、脏腑功能、邪气等对睡眠有影响。在此基础上,分析失眠的病机为阳盛阴虚,而气血衰少、脏腑功能失调、外感或内伤邪气、因虚等也可导致失眠。而其总的治则为调整脏腑气血阴阳。而治疗方面则采用了辨证论治与针灸、推拿等多种方式。中医心理学则在此基础上提出了情志病变与失眠互为因果的观点,强调了心理治疗在失眠治疗中的重要性,并提出了一系列具有中医特色的心理治疗方法。现代医学对于对失眠的认识也经历了从生物医学到心身医学的发展转变,从最初的单纯药物治疗到现在的药物与心理的综合治疗,心理因素在失眠发生发展中的作用日益得到医患双方的重视。2.编制了具有中国文化特色的能快速鉴别主客观失眠的主观性失眠评定问卷本研究遵循心理学测量问卷的编制原则,参考现代心理测量问卷规范的编制程序与方法,构建主观性失眠评定问卷的理论框架和症状与体征、认知、行为、情绪感受、社会功能五个维度,编制了主观性失眠评定问卷,确定由26个条目构成的正式问卷。本研究对主观性失眠评定问卷的可行性、信度和效度进行了检验。问卷的接受性和回收率均为100%,其平均完成时间为4.73±2.18分钟,超过90%的失眠者完成本问卷的时间为3-8分钟,本问卷有较好的临床可行性;其重测信度在0.9以上,Crobach'α系数值和分半信度系数值均大于0.7,说明本问卷有良好的信度;该问卷经内部一致性检验,除条目2与问卷得分相关系数略低于0.20外,其余条目与问卷得分的相关系数在0.222-0.570之间,各维度与总问卷的相关系数在0.488-0.639之间,各条目与其所属维度得分的相关系数在0.317-0.917之间,而它们与其它维度得分的相关系数值均小于与其所属维度得分的相关系数值,P值均小于0.01,呈显著相关,说明本问卷有较好的内容效度。本问卷与匹兹堡睡眠质量指数量表得分的相关系数r值大于0.8,表明本问卷有较好的校标关联效度。探索性因素分析提取的公因子基本对应理论构想的情绪感受、症状与体征、行为、认知和社会功能五维度,说明本问卷具有较好的结构效度。本问卷的效应尺度为2.84,本问卷有良好的反应度。本问卷的客观失眠指数可以区分主客观失眠,低于3分为主观性失眠,与体动记录仪监测结果的相关系数大于0.7,呈显著相关,本问卷可以快速鉴别主客观性失眠。结论:1.睡眠受到多种因素的影响,社会心理因素在失眠的发生发展以及转归中起着十分重要的作用。对于非器质性失眠者,社会心理因素更是主要的致病因素。2.研制的主观性失眠评定问卷经各项统计学检验以及与匹兹堡睡眠质量指数量表比较,显示本问卷具有较好的信度和效度以及良好的临床可行性,为临床了解非器质性失眠者的非理性思维和行为反应模式提供了具有中国文化特色和符合中国人语言习惯的测量工具。3.研制的主观性失眠评定问卷可用于快速鉴别主观性失眠。4.运用本问卷对非器质性失眠者进行调查,结果显示心理因素与失眠者病情的发展关系密切。而随着失眠病情的好转,问卷得分明显下降。将主观性失眠评定问卷与匹兹堡睡眠质量指数量表评定结果进行比较,两者有很好的相关性,验证了本问卷测量的可靠性,能为临床上影响非器质性失眠者病情的心理因素方面的评定提供方便、快捷的测评方式。
[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,.

【学位授予单位】：广州中医药大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R256.23

【参考文献】