我想念我自己:反芻反應在術後乳癌女性之身體外觀差距與創傷後壓力症狀及憂鬱症狀之影響

Abstract

目的：本研究旨在探討經歷手術後的乳癌女性，在身體外觀變動中，覺知術前身體外觀與目前身體外觀之差距，以及理想身體外觀與目前身體外觀間之差距，是否會對其憂鬱症狀與創傷後壓力症狀之嚴重程度具有預測效果，以及探討反芻反應在上述歷程中是否扮演一脆弱認知因子的角色，使得患者在覺知差距時可能採用較不具適應的認知因應而影響後續的心理症狀表現。此外，本研究亦探索創傷後壓力症狀中的侵入性症狀是否扮演觸發其他類群創傷後壓力症狀的重要因子，並將嘗試整合檢驗身體外觀差距、反芻反應、侵入性症狀以及其他類群之創傷後壓力症狀之關聯，提出術後乳癌女性在創傷後壓力症狀之病理模式。最後，對於不同年齡層歷經手術後的乳癌女性，其覺知身體外觀差距的衝擊以及心理症狀的嚴重程度可能有所差異，本研究也將進一步延伸探討。方法：本研究透過乳房手術外科門診和乳癌防治基金會衛教活動招募手術後之乳癌女性，有效樣本共265名，平均年齡為54.15歲（標準差為10.95歲），參與者於知情同意後，完成身材外觀評估量表、中文反應風格量表短版（CRSQ-SF）、簡式症狀量表（BSI）憂鬱分量表以及創傷後壓力症狀指標量表短版（PTSRI-SF）等量表。結果：（1）術前與目前身體外觀差距，以及理想與目前身體外觀差距，皆能顯著正向預測憂鬱症狀與創傷後壓力症狀的嚴重程度；（2）反芻反應可分別中介術前與目前身體外觀差距和理想與目前身體外觀差距對憂鬱症狀以及創傷後壓力症狀嚴重程度之預測；（3）反芻反應與侵入性症狀可序列中介術前與目前身體外觀差距和理想與目前身體外觀差距，對逃避症狀、認知與負向情緒改變以及警醒性與反應性改變嚴重程度之預測；（4）不同年齡層的術後乳癌女性，年輕組顯示有較高程度的反芻反應與創傷後壓力症狀之表現，然而，在身體外觀評分上不同年齡組之間皆無顯著差異。討論：研究結果顯示術後乳癌女性在覺知術前與目前身體外觀差距，以及理想與目前身體外觀差距皆能反映患者在憂鬱症狀與創傷後壓力症狀的負向心理適應，而反芻反應在認知因應歷程中也被證實為一脆弱認知因子。侵入性症狀在整體創傷後壓力症狀為重要之核心症狀，可能是術後乳癌女性在覺知身體外觀差距之歷程，惡化或維持創傷後壓力症狀的來源。此外，亦發現年輕術後乳癌女性整體而言具較差的心理適應表現。本研究也將依前述結果，提出對未來研究與臨床應用的建議。

OBJECTIVE: This study aimed to first examine whether perceiving the discrepancy between pre-surgery and current physical appearance (D_PACA) and discrepancy between ideal physical appearance and current physical appearance (D_IACA) could predict the severity of depressive symptoms and posttraumatic stress symptoms (PTSS) in the women with breast cancer (BC) who have undergone BC surgery. Second, viewing rumination as a cognitive vulnerability factor, this study also explored whether those patients adopt maladaptive cognitive strategy to cope with the perceived discrepancy may develop subsequent psychological symptoms. In addition, the current study explored whether intrusion symptoms played an important role in triggering other types of PTSS. By integrating the examinations of the physical appearance discrepancy, rumination, intrusion, and other types of PTSS, this study expected to propose a pathological model of PTSS in postoperative women with BC. Last, the study examined postoperative women with BC in different ages to seek whether age may affect the association of physical appearance and severity of psychological symptoms. METHODS: A total of 265 postoperative women with BC were recruited from the Breast Surgery Clinic of NTUH and Foundation of Breast Cancer Prevention, with average age 54.15±10.95 years. Measures included physical appearance evaluation inventory, Chinese Ruination Style Questionnaire-Short Form (CRSQ-SF), Breif Symptom Inventory (BSI)-Depression Subscale, and Post-Traumatic Stress Reaction Index-Short Form (PTSRI-SF). RESULTS: (1) The D_PACA, as well as the D_IACA, could significantly predict the severity of depressive symptoms and PTSS. (2) Rumination could respectively mediate the predictive effects of the D_PACA and D_IACA on the severity of depressive symptoms and PTSS. (3) Rumination and intrusions could serially mediate the predictive effects of the D_PACA and D_IACA on the severity of avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity, respectively. (4) The younger group of postoperative women with BC showed a greater severity of rumination and PTSS; however, there was no significant difference in physical appearance score between different age groups. DISCCUSION: Perceiving the D_PACA as well as the D_IACA in the postoperative BC women may affect the patient’s negative psychological adaptation to depressive symptoms and PTSS, while rumination was confirmed as a cognitive vulnerability factor in cognitive coping process. In addition, intrusions could be seen as an important core symptom of PTSS, and might lead to other PTSS in postoperative BC women upon perceiving the physical appearance discrepancy. Furthermore, younger postoperative BC women were also found to have poorer psychological adjustment. Based on the above findings, future research and clinical implications are suggested.