知覺污名、身體意象不滿預測憂鬱及創傷後壓力症狀之序列中介效果：以八仙燒傷事故倖存者為例

Abstract

目的：憂鬱症及創傷後壓力症（Posttraumatic Stress Disorder [PTSD]）為燒傷後最為常見的心理疾患；另一方面，基於研究者自身經驗與臨床觀察，以及現存實徵研究的累積，顯示身體外觀改變及知覺污名為燒傷者產生心理適應困難的重要因素，其中認知行為觀點身體意象模型為目前應用最廣的觀點。實證研究發現身體意象不滿（Body Image Dissatisfaction [BID]）與知覺污名有顯著相關，身體意象不滿可顯著預測燒傷後憂鬱症狀，而對疤痕及外觀的擔憂可顯著預測PTSD症狀，且性別、疤痕可見度及外觀重要度可能扮演調節作用。有鑑於此，本研究擬以認知行為觀點身體意象模型為基礎建立研究架構，檢視：（一）知覺污名與身體意象不滿預測憂鬱及PTSD症狀的序列中介效果，與（二）性別、臉部是否燒傷、外觀重要度等變項是否有調節作用。研究方法：以八仙塵燃倖存者作為對象，評估時間點為事故後兩年（T1）與三年（T2），共106名完成兩波調查。參與者平均年齡為23.97±4.1歲，平均體表燒傷面積為50.5±19.4%，有61.3%為女性。本研究透過量表蒐集資料，並以（一）相關法檢視變項間關係，（二）Process（Model 6）檢視序列中介效果，及（三）階層迴歸分析檢視調節式中介效果。研究結果：（一）相關法發現T2的憂鬱及T1的PTSD症狀皆與T2的PTSD症狀有顯著正相關，且T2的憂鬱及PTSD症狀皆和T1的憂鬱、知覺污名、身體意象不滿有顯著正相關。（二）Process（Model 6）分析發現，分別控制年齡、教育年數、燒傷面積、T1的憂鬱或PTSD症狀後，T1的主觀疤痕嚴重度透過知覺污名及身體意象不滿到T2的憂鬱症狀之關係為完全中介，且序列中介效果顯著；T1的主觀疤痕嚴重度透過知覺污名及身體意象不滿到T2的PTSD症狀之關係為部分中介，然序列中介效果不顯著。（三）階層迴歸分析發現，臉部燒傷調節「主觀疤痕嚴重度影響知覺污名」及「知覺污名影響身體意象不滿」的關係，而外觀重要度調節「知覺污名影響憂鬱症狀」、「主觀疤痕嚴重度影響PTSD症狀」及「身體意象不滿影響PTSD症狀」的關係。討論：本研究以Cash的身體意象模型理論為基礎建立研究架構，結果發現在燒傷群體中，身體意象（態度成分）確實受到身體外觀改變（燒傷事件造成疤痕、主觀疤痕嚴重度）及人際經驗（知覺污名）之影響，並使個體產生情緒症狀（憂鬱及PTSD症狀），此發現應有助於理解燒傷族群發展出心理症狀之病理機制。另外，針對疤痕與心理困擾間的關係，本研究結果發現臉部燒傷與否可調節知覺污名與身體意象不滿的關聯，較傾向支持可見假說。最後，本論文以研究的發現為基礎，討論臨床應用的角度，並提出未來研究方向的建議。

Background: Depressive Disorder and Posttraumatic Stress Disorder (PTSD) are the most prevalent psychiatric disorders following burn injury. Bbased on personal experiences, clinical observations and existing research, body appearance changes and perceived stigmatization could play important roles in causing difficultities for burn survivors following the trauma. Among theories, the cognitive-behavioral approach on body image is the most widely used perspectives, and studies reveal that body image dissatisfaction (BID) was significantly correlated with perceived stigmatization (PS); BID could predict depressive symptoms after burn traumas, and concerns for scars/appearances could predict PTSD; futhermore, gender, scar visibility and appearance importance might play moderated roles in the links. Accordingly, this study aimed to investigate: (1) the serial mediating effects of PS and BID on the relationships between subjective scar severity (SSS) and depressive/PTSD symptoms; (2) the moderated mediating effects of gender, scar visibility (facial burned) and appearance importance on this serial mediating model. Methods: Participants were 106 survivors of the Formosa Fun Coast Burn Accident that occurred in 2015, with mean age 23.97±4.1 years, mean total body surface area burned (TBSA) 50.5±19.4%, and 61.3% females. A two-wave prospective design was conducted, collecting data at two years (Time 1 [T1]) and three years (Time 2 [T2]) after the accident. Self-report scales were administered individually. The study examined: (1) the relationships between variables by Pearson’s correlation analyses; (2) the serial mediating effects by Hayes’ 2017 PROCESS macro for SPSS (Model 6); and (3) the moderated mediating effects by hierarchical regression analyses. Results: (1) T2 depressive and T1 PTSD symptoms were significantly positively correlated with T2 PTSD symptoms, and T2 depressive and PTSD symptoms were significantly positively correlated with T1 depressive symptoms, PS, and BID. (2) Process (Model 6) analyses indicated that, after controlling age, educational years, TBSA, and T1 depressive/PTSD symptoms, PS and BID fully moderated the relationship between SSS and depressive symptoms with significant serial mediating effect, while PS and BID can only partially moderated the relationship between SSS and depressive symptoms with no significant serial mediating effect. (3) Hierarchical regression analyses indicated that facial burned moderated the relationship between “SSS to PS” and “PS to BID”, and appearance importance moderated the relationship between “PS to depressive symptoms”, “SSS to PTSD symptoms” and “BID to to PTSD symptoms”, respectively. Discussion: The results together suggested that, in burn patients, body image (especially the attitude component) was influenced by body appearance changes (e.g., scars after burn) and interpersonal experiences (e.g., PS), and in turns,led to emotional symptoms (i.e., depression and PTSD symptoms). These findings may help to understand the etiology of post-burn psychological disorders. Futhermore, the finding that facial burns can moderate the association between PS and BID also support the visible hypothesis. Finally, clinical implications and directions for future research are suggested.