臺灣博碩士論文加值系統

近年來，精神疾病患者透過醫療院所取得證明申請勞工保險失能給付的案例有以倍數成長的趨勢。部分申請者可能在金錢的誘因下，會出現刻意偽裝或企圖誇大症狀的情形。但目前國內極度缺乏有效的標準化測驗或客觀的工具用以偵測此類的現象。本研究的目的即在，參照過去國內外現有的研究及做法，試圖檢驗現行的認知測驗在偵測偽裝或誇大症狀傾向的效用。
本研究採參與者間設計，先將參與者分成四組：（1）未申請勞保給付之精神疾病患者（病患組，n = 25）；（2）偽裝認知功能障礙之健康參與者（偽裝組，n = 25）；（3）健康參與者（對照組，n = 24）與（4）欲申請勞保失能給付之精神病患者（勞保組，n = 27）。本研究所採行之工具，除了數項經國內外研究證實可被做為偵測偽病之測驗之外(記憶偽裝測驗、雷氏15項目記憶與再認測驗、以及選擇反應時間作業)，同時也採用一般的神經心理測驗進行檢驗（簡易智能狀態評估表、記憶廣度測驗、中文年級認字量表、瑞文氏標準圖形推理測驗、加州語文學習測驗第二版、簡易視覺記憶測驗修訂版、色字干擾作業、）。在資料分析上，先比較前三組在各項認知或臨床症狀表現上的差異；之後，再根據比較後的結果，篩檢出偽裝組表現顯著低於病患組與對照組，但病患組與對照組無顯著差異的測驗指標，個別進行敏感度與特異度分析並選定該指標的切截分數。
結果顯示，記憶偽裝測驗（Test of Memory Malingering）中的「嘗試二」與「延宕再認嘗試」及選擇反應時間作業（Choice Reaction Time Task）中的錯誤數三項指標最具檢驗效力，敏感度與特異度皆分別達76.00% 與95.92% 以上。
進一步比較病患組及勞保組在這些指標的偵測率後發現，在記憶偽裝測驗中的「嘗試二」與「延宕再認嘗試」，各有51.85%勞保組的參與者被測驗判斷有偽裝或誇大認知功能障礙的傾向，但在病患組中，得分低於此兩指標切截分數的人數比例僅分別占該組人數的4.00% 和8.00%；在選擇反應時間作業之錯誤數方面，則有30.77%的勞保組參與者被測驗判斷有誇大認知功能障礙的傾向，病患組則為8.00%。雖然本研究無法直接證明欲申請勞保給付的參與者是否有偽裝或誇大認知功能障礙的意圖，但勞保組被懷疑有此傾向的比率的確遠高於病患組。
本研究的結果顯示，申請勞保給付的精神病患很可能有偽裝或誇大認知功能障礙的意圖，且其比例可能遠高於一般的精神疾病患者，頗值得臨床實務工作者重視。

The number of psychiatric patients claiming for the Labor Insurance Disability Allowance has been escalating in recent years. It is possible that some patients may simulate or exaggerate their deficits under the influence of monetary incentives. However, there is general lack of standardized or objective tools for detecting this possibility. The aims of the present study intend to examine the applicability of a set of neuropsychological tests for detecting the likelihood of deliberate exaggeration of symptoms or simulation of cognitive impairments.
The present study was based on a between-participant design. The participants were allocated to four groups: (1) the non-claimant patient group (patient group, n = 25); (2) analogue dissimulated group (dissimulated group, n = 25); (3) the healthy volunteer group (control group, n = 24); and (4) the allowance-claiming patient group (claiming group, n = 27). In addition to the standardized tools for testing malingering, some neuropsychological tests were also used for this present study (the Mini-Mental Status Examination, Digit Span of the Wechsler Adult Intelligence Scale-III, Raven’s Standard Progressive Matrices, Chinese Graded Word Reading Test, California Verbal Learning Test-II, Brief Visual Memory Test-Revised, Color-Word Interference Task, the Test of Memory Malingering [TOMM], Rey 15-Item Memory and Recognition Tests, and Choice Reaction Time Task). The performance of the patient group, dissimulated group and control group on all the cognitive tests were compared first. If the testing scores revealed significant differences between the dissimulated group and the other two groups, respectively, but not for those differed significantly between the patient and control groups, the measures were selected for testing the sensitivity and specificity for detecting simulation of deficits and deriving the cutoff scores.
The results showed the Trial 2 and the Retention Trial of the Test of Memory Malingering (TOMM) and the error index of a Choice Reaction Time Task were the most useful tests, with the values of sensitivities and specificity all well above76%and 93%, respectively.
In addition, the detection rates for exaggeration of cognitive deficits were calculated for participants in the patient and claiming groups. There were 51.85% of the allowance-claiming patients failed on the TOMM, but only 8.00% of the patient group failed on this test. In the case of the measure for the Choice Reaction Time Task, there were 30.77% of the allowance-claiming patients failed, whereas there were only 8.00% of patients without allowance-claiming failed on this test. Although it is difficult to verify that the patients in the claiming group intended to simulate or exaggerate their deficits in the present study, the proportion of suspected dissimulators in this group was significantly higher than that of the non-claiming patients.
The present study suggested the psychiatric patients who intended to claim for the Disability Allowance were very likely to simulate or exaggerate their deficits; and the proportion of these patients may be much higher than the non-claiming patients. This phenomenon is noteworthy for the clinical practitioners.

目錄
第一章 緒論................................................1
1.1 研究背景...............................................1
1.2 「偽病」的定............................................4
1.3 「偽裝認知障礙」的偵測....................................6
1.3.1 偵測「偽裝認知功能障礙」的策略...........................6
1.3.1.1 地板效應...........................................7
1.3.1.2 錯誤量............................................7
1.3.1.3 症狀有效性檢驗......................................8
1.3.1.4 非典型表現.........................................8
1.3.1.5 心理後遺症.........................................9
1.3.1.6 表現曲線法........................................10
1.3.2 傳統偵測偽裝測驗的爭議.................................11
1.3.3 偵測偽裝研究的設計....................................12
1.3.4 合併式的偽病研究設計..................................16
1.4 勞保失能給付申請者之特徵.................................17
1.5 研究目的..............................................19
第二章 研究方法............................................22
2.1 參與者................................................22
2.2 施測工具..............................................23
2.2.1 基本智能評估.........................................23
2.2.1.1 簡易智能狀態評估表...................................23
2.2.1.2 魏氏成人智力測驗第三版之記憶廣度分測驗..................24
2.2.1.3 瑞文氏標準圖形推理測驗...............................25
2.2.1.4 中文年級認字量表....................................26
2.2.2 偽裝認知功能障礙偵測作業...............................27
2.2.2.1 加州語文學習測驗....................................27
2.2.2.2 簡易視覺記憶測驗....................................28
2.2.2.3 色字干擾作業.......................................29
2.2.2.4 記憶偽裝測驗.......................................31
2.2.2.5 雷氏15項目記憶測驗..................................32
2.2.2.6 雷氏15項目再認嘗試..................................32
2.2.2.7 選擇反應時間作業....................................33
2.3 施測程序..............................................34
2.4 資料分析..............................................35
第三章 研究結果............................................39
3.1 基本資料..............................................39
3.2 基本心智功能之偽病偵測...................................41
3.3 偽裝認知功能障礙偵測作業..................................43
3.3.1 雷氏15項目記憶和再認測驗...............................43
3.3.2 記憶偽裝測驗.........................................45
3.3.3 簡易視覺記憶測驗......................................48
3.3.4 加州語文學習測驗......................................50
3.3.5 色字干擾作業.........................................54
3.3.6 選擇反應時間作業......................................57
3.4 各偵測偽裝測驗之效度分析.................................61
3.4.1 ROC曲線與切截分數之分析................................61
3.4.2 勞保組之偽裝認知功能障礙分析............................64
第四章 討論................................................69
4.1 偽裝組之認知功能表現.....................................69
4.2 認知測驗偵測偽裝的效用...................................70
4.2.1 準確性較高的偽裝偵測指標................................71
4.2.1.1 記憶偽裝測驗........................................71
4.2.1.2 選擇反應時間作業.....................................72
4.2.2 其他偽裝偵測指標......................................75
4.2.2.1 記憶廣度測驗.......................................75
4.2.2.2 瑞文氏標準圖形推理測驗...............................76
4.2.2.3 簡易智能狀態測驗....................................76
4.2.2.4 加州語文學習測驗....................................77
4.3 偵測偽裝認知功能障礙策略..................................79
4.4 偵測偽裝認知功能障礙測驗之效果分析..........................80
第五章 結論................................................82
參考文獻..................................................85
附錄一 偽裝組指導語.........................................96
附錄二 偵測偽病測驗各項指標之切截分數與其區辨之準確性….............97

圖表目錄
表次
表3-1勞保組、病患組、偽裝組與控制組人口學變項之頻率、平均值、標準差與95%信賴區間估計值..............................................40
表3-2病患組、偽裝組與對照組在基本智能評估之結果...................42
表3-3勞保組、偽裝組與控制組在雷氏15項目記憶測驗之結果.............44
表3-4病患組、偽裝組與對照組在加州語文學習測驗作業之結果............53
表3-5病患組、偽裝組與對照組在色字干擾測驗之平均反應時間、正確數與標準誤........................................................55
表3-6偽裝者與真實狀態作答者有顯著差異之測驗指標...................62
表3-7偵測偽裝測驗各項指標之切截分數與其區辨之準確性................63
表3-8勞保組於各測驗之表現結果.................................65
表3-9勞保組和病患組在各項指標切截分數表現之比較表.................67

圖次
圖3-1 病患組、偽裝組與對照組在TOMM各種嘗試得分之平均值與標準誤...46
圖3-2 病患組、偽裝組及對照組所有參與者於TOMM各種嘗試總分莖葉圖...47
圖3-3 各組參與者在簡易視覺記憶和再認測驗得分之平均值與標準誤.....49
圖3-4 病患組、偽裝組與對照組在加州語文學習測驗之學習能力指標之平均數與標準誤......................................................51
圖3-5 病患組、偽裝組與對照組於選擇反應時間作業之平均反應時間及其與標準化樣本間之線性關係..........................................59
圖3-6 病患組、偽裝組、和對照組之各項選擇反應時間作業指標與錯誤總數之平均數與標準誤................................................60

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