精神病患的生命凝聚感與活動參與

Abstract

研究背景及目的 Antonovsky提出生命凝聚感(sense of coherence, SOC)的概念，認為當一個人可以理解其生活的經驗、應付生活事件的要求、並且獲致生活的意義，便能呈現出最佳的適應表現。此概念對於精神病患之日常生活調適、尋求生命及生活意義上，具備極高的臨床實務應用潛能。因此，本研究將探討中文版生命凝聚感量表(13題版)於精神病患之信效度，以及生命凝聚感及活動參與的相關性，並探討活動參與、生活品質、動機、生活滿意指數、憂鬱症狀對於生命凝聚感的預測力。期待未來可以依此研究結果，進一步規劃可促進精神病患朝向健康且具理論基礎的介入模式。 研究方法 本研究採用橫斷面研究設計，預計收集精神科門診、日間留院、社區工作坊處於症狀緩解的病患319位。採立意取樣法，邀請具有DSM-Ⅳ診斷為精神分裂症、憂鬱症，年齡18-65歲、具備理解及填答本問卷能力者參與研究。先檢測中文版生命凝聚感量表(13題版)之信效度。而在生命凝聚感現象探討部分，使用描述性統計法及推論統計法，探索精神病患於中文版生命凝聚感量表(13題版)之得分情形與相關人口學變項間的關係。同時檢測此量表與日常活動參與問卷(Activity Participation Rating Questionnaire, APRQ)間的相關性，並使用逐步多元迴歸分析法，對上述所有量表對生命凝聚感的預測力作檢測。 研究結果 本研究共收集319份有效問卷。結果顯示，中文版生命凝聚感(13題版)以確證式因素分析呈現單一因素結果，且有可接受的內部一致信度(Cronbach alpha =0.84)及再測信度(r=0.53, p<0.001)，並支持此量表的同時效度。 在活動參與部分，精神分裂症及憂鬱症個案呈現在工作類的活動時數及負向感受都顯著高於休閒類，且在憂鬱症個案的投入程度、正向感受部分也呈現休閒類高於工作類的趨勢。在活動目的方面，精神分裂症個案與憂鬱症個案皆為調劑身心，其次為經濟。但精神分裂症更有希望和人在一起的目的；憂鬱症個案則有責任與別人期待的目的在其中。在其他參與特質方面，精神分裂症比憂鬱症個案有較固定、侷限的活動場所及共同參與者。 在活動參與與生命凝聚感部分，精神分裂症個案在僅在活動參與感受及因受限產生的負向感受方面，與生命凝聚感間有相關；憂鬱症個案則在活動類別、活動時數、有無共同參與者，以及參與感受與生命凝聚感達顯著水準。 精神分裂症的生命凝聚感與生活品質、生活滿意度、無動機型、憂鬱情緒、參與感受，以及受限感受中的負向感受呈現顯著相關。其中又以生活品質心理範疇為最主要解釋因子(43%)，而生活品質心理範疇、憂鬱情緒、生活品質社會關係共可以解釋精神分裂症47%的變異量。在憂鬱症個案的生命凝聚感與生活品質、生活滿意度、自主型及無動機型、憂鬱情緒，以及參與感受呈現顯著相關。其中以憂鬱情緒為最主要的解釋因子(47%)，憂鬱情緒、生活滿意度、生活品質生理範疇、活動參與正向感受共可解釋56%的生命凝聚感變異量。 討論與結論 本研究結果證實，中文版生命凝聚感量表(13題版)具有可接受的信效度。由於因素分析結果呈現單一因素，建議使用此量表時以採計總分為宜。 在活動參與方面，精神病患在工作類活動的負向感受明顯較從事休閒類活動來得高，但是又有最多的活動時間在從事工作類活動。精神分裂症較憂鬱症個案在活動參與上呈現較侷限且固定的人際、生活範圍，且隱含人際歸屬的渴望。而憂鬱症個案認為有意義且會規律從事的活動中，更帶有責任以及別人期待的目的，可能暗示憂鬱症個案在活動參與上有符合重要他人的意義在其中。 在生命凝聚感與活動參與方面，推測對於精神分裂症個案而言，不管從事怎樣的活動類別，只要在活動當中能夠促進投入程度、給予正向感受、增強自我價值感、降低負向感受及因受限產生的負向感受，可能會有助於精神分裂症個案的生命凝聚感。在憂鬱症個案則呈現工作類活動的生命凝聚感顯著低於休閒類，且在活動時數上越長，生命凝聚感越低，或許暗示在憂鬱症個案所從事的工作類活動過程中，並無助於提升個案的生命凝聚感。 在有關生命凝聚感的預測力方面，憂鬱情緒為兩診斷皆有的顯著解釋因子。且在精神病患的生命凝聚感中，生活品質的心理範疇與憂鬱情緒各為精神分裂症與憂鬱症最主要的解釋因子，或許暗示生命凝聚感所探討的複雜面向中某部分與此二者的共通處。另外，活動參與的正向感受或許可以作為精神復健臨床介入時，提昇憂鬱症個案生命凝聚感的媒介。

Background Antonovsky presented the concept of “sense of coherence” (SOC). It described that a person could adjust his life well if he could comprehend the experience of life, manage his life events, and gain the meaning of life. This concept has high application potential for psychiatric patients in adjustment of daily life and searching for the meaning of life. Therefore, the purposes of this study were to evaluate the reliability and validity of Chinese sense of coherence scale (SOC-13) in psychiatric patients, to find the correlation between SOC and activity participation, and to reveal the predictability of activity participation, quality of life, motivation, satisfaction of life and depressive symptoms to SOC. According to the study result, we wish to develop an evidence-based interventional model to promote mental health in psychiatric patients in the future. Methods This study was a cross-sectional design, collecting patients from psychiatric outpatient department, day-care center and sheltered workshop. We used purposive sampling method, and the inclusion criteria were those who were diagnosed to have schizophrenia and depression, aging 18-65 years, and having the ability to understand and answer the questionnaire. First, we test the reliability and validity of SOC-13, and then to evaluate the phenomenon of SOC. We used descriptive and inferential statistics to study the relationship between SOC-13 and related demographics. We also tried to reveal the correlation between SOC and activity participation, and used stepwise multiple regression to test the predictors to SOC. Results We collected 319 effective questionnaires. It had acceptable internal consistency reliability( Cronbach alpha=0.84) and test-retest reliability (r=0.53, p<0.001). The result of constructive validity showed that Chinese SOC-13 had single factor, and support the concurrent validity of SOC-13. In activity participation, schizophrenic and depressive patients spent significantly more hours and had more negative affects in working activities than in leisure ones. Depressive patients also tend to have more sense of involvement and more positive affects in leisure activities than in working ones. The main common purpose of activity participation for schizophrenic and depressive patients was to provide physical and mental relaxation, and the second purpose was for economy. Another purpose for schizophrenic patients was to be together with others. Depressive patients had other purposes of responsibility and meet others’ expectations. Schizophrenic patients had other characteristics including more constant and limited activity sites and co-participation. In activity participation and SOC, schizophrenic patients had correlation between SOC and subjective feeling of participation and negative affects of limitation. In depressive patients, there was significant correlation between SOC and activity type, duration, alone or co-participation, and subjective feeling of participation. In schizophrenic patients, the SOC had significant correlation with quality of life(QOL), satisfaction with life, loss of motivation, depressive symptoms, subjective feeling of participation, and negative affects of limitation. The psychological domain in QOL was the main factor (43%). The psychological domain in QOL, depressed mood, and social relationship in QOL accounted for 47% of variability. In depressed patients, the SOC had significant correlation with QOL, satisfaction with life, automatic and loss of motivation, depressive symptoms, and the sense of involvement, positive affects, self worth. Depressed mood was the main factor (47%). Depressed symptoms, satisfaction with life, physical domain in QOL, and positive affects of participation accounted for 56% of variability. Conclusion This study revealed that SOC-13 had acceptable validity and reliability. Because the results were single factors, total scoring was suggested while using this scale. In participation of activities, Schizophrenic patients had more limited and constant interpersonal relationship, so they had the desire to join others. Depressed patients considered the purpose of responsibility and others’ expectation in the meaningful and regular activities, which indicated that they had to cohere with the important others. In SOC and activity participation, for schizophrenia we might help them to increase their SOC with activities by promoting sense of involvement, giving positive affects, increasing self worth and decreasing negative affects. In depressed patients, working activities might not be able to increase SOC, and related others played an important role to promote SOC.