臺灣博碩士論文加值系統

研究背景與目的：原發型失眠症的治療可以分成兩大部分：非藥物治療以及藥物治療，目前常使用來治療失眠的藥物主要包括Benzodiazepine (BZD)類藥品及作用於BZD接受體之非BZD類安眠鎮靜劑(non-selective Benzodiazepine - Receptor Agents；簡稱BZRA)。短期使用助眠劑可以改善失眠的症狀，但許多失眠患者因為害怕停用藥物就無法睡覺，仍長期持續使用助眠劑，漸漸的對藥物產生依賴、或反彈性失眠等戒斷症狀，臨床上通常會建議病患採用逐步減藥的方式以降低助眠劑的使用，過去用以說明減藥是否成功的研究大多著重在藥物相關因素，因此，本研究將探討失眠患者的心理認知因素與減藥行為之關係，並檢視不良的睡眠信念是否透過自我效能及決策權衡的中介效果影響減藥行為。

研究方法：研究當中的原發型失眠患者主要來自醫院轉介，共37人（男13人，女23人，平均年齡46.7歲），所有受試者在進行減藥計畫前(第一週)及完成減藥計畫後(第10週)，填寫睡眠失功能信念與態度量表（Dysfunctional beliefs and attitudes about sleep questionnaire，簡稱DBAS）、決策權衡問卷(Decision Balance questionnaire)、單題自我效能量尺(Single Self-Efficacy Rating Scale)，並在為期 10週的減藥計畫期間每天填寫睡眠日誌以了解其睡眠參數變化及藥物使用狀況。

研究結果：不良的睡眠信念與減藥行為的相關未達顯著，顯示不良的睡眠信念與減藥行為沒有直接效果，不良的睡眠信念與減藥的決策權衡、減藥的自我效能的相關皆未達顯著，無法繼續探討論三者與減藥行為的中介關係，而減藥行為與決策權衡(r=.358,p<.05)及自我效能(r=.632,p<.001)分別達到顯著性的相關。進一步透過階層迴歸的方式探討人口學變項、疾病與藥物相關變項、心理認知變項對減藥劑量的影響，得到的結果發現三個區組能夠有效解釋依變項減藥行為的64.7% (F(3,30) =6.865，p<.001)，解釋力增加量達統計水準(∆F(3,30)= 10.564，∆p<.001)。
結論：減藥的自我效能以及決策權衡可以預測減藥行為，患者若有較高的自我效能以及傾向評估減藥的好處，則可以減少較高百分比的助眠劑劑量。原發型失眠患者的減藥行為除以原先的藥物觀點來評估之外，心理認知因素更是影響其減藥行為的重要指標。

Introduction: Treatments of primary insomnia include pharmacological therapy and non pharmacological therapy. The medications for insomnia are mainly Benzodiazepine (BZD) and non-selective Benzodiazepine-Receptor Agents (BZRA) that modulate the BZD receptors. Hypnotic use in the short term could improve sleep. However, some insomniacs could not stop hypnotic use because they are afraid of being unable to fall asleep due to the discontinuity of medicine. Long term hypnotic use can cause gradually dependence, rebound insomnia, as well as withdraw symptom. In clinical settings, gradual dose tapering is usually applied to reduce the use of hypnotics. Numerous researches have been conducted to assess the predictability of some pharmacological factors on the successfulness of hypnotic tapering. This research is to investigate the association between cognitive factors and hypnotic tapering, with the hypothesis that dysfunctional beliefs affect hypnotic tapering through the mediating effect of self efficacy and decision balance.

Methods: Thirty seven patients with primary insomnia, including 13 men and 23 women (average age: 46.7) were recruited from a general hospital. All participants had to complete a set of questionnaires including Dysfunctional Beliefs and Attitudes about Sleep Questionnaire (its acronym DBAS), Decision Balance questionnaire and Single Self-Efficacy Rating Scale before and after hypnotic tapering plan. During the 10-week drug tapering period, each participant was required to keep a sleep diary to evaluate the changes in sleep parameters and the status of drug use.

Result: The results showed that the correlation between dysfunctional beliefs and the amount of drug tapering did not reach significance. It indicates there is no direct correlation between dysfunctional beliefs and tapering behavior. Therefore, the hypothesis that dysfunctional beliefs affect hypnotic tapering through the mediating effect of self efficacy and decision balance was not proven. However, decision balance (r=.358, p<.05) and self efficiency (r=.632, p<.001) significantly correlated with tapering behavior. Further analyses with hierarchical multiple regression to explore the predictability of demographic variables, variables relevant to disease and drug use, and cognitive variable on drug tapering. It was found that these three variables can explain the amount of drug reduction up to 64.7 %.

Conclusion: In sum, the results indicate that the effectiveness of drug tapering could be predicted by self efficacy and decision balance. The higher self efficacy and the more positive evaluation of drug discontinuation a patient has, the more reduction of hypnotic dose can be obtained following a graduate tapering program. It implies that psychological factors could be important in the evaluation for drug reduction in clinical patients.

第一章 緒論…………………………………………………………………… 1

第二章 文獻探討
 第一節原發性失眠症之定義、流行病學研究與治療………………… 4
 第二節認知信念與失眠…………………………………………………10
 第三節自我效能 ………………………………………………………12
第四節 決策權衡…………………………………………………………15
 第五節研究目的與假設…………………………………………………17

第三章 研究方法
 第一節 研究對象 ………………………………………………………19
 第二節 研究工具 ………………………………………………………20
 第三節 研究程序 ………………………………………………………24
 第四節 資料分析 ………………………………………………………27
.
第四章 研究結果
 第一節 人口學資料、疾病與藥物使用狀況 …………………………28
 第二節 減藥前後相關變項之差異 ……………………………………29
 第三節 不合理的睡眠信念、自我效能、決策權衡與減藥行為之相關…32
第四節 減藥結果 ………………………………………………………37

第五章 討論
 第一節 減藥相關結果 …………………………………………………40
 第二節 認知變項用以預測減藥行為……………………………………42
 第三節 減藥成功與否……………………………………………………44
第四節 研究限制與未來展望……………………………………………46

參考文獻 ……………………………………………………………………48

附錄
附錄一 睡眠失功能信念及態度量表…………………………………………55
附錄二 助眠劑使用態度問卷 ………………………………………………58
附錄三 睡眠日誌 ……………………………………………………………59

ㄧ、中文部分

行政院主計處：九十四年國人健康概況與健康檢查情形調查。行政院，2005年。

行政院主計處：九十年台灣地區社會發展趨勢調查統計結果。行政院，1999年。

精神疾病的診斷與統計（孔繁鐘編譯）（民88）。臺北市：合記圖書出版社。（原著出版年：1997年）。

林詩淳、楊建銘、許世杰（民95）。失眠嚴重度量表、睡前激發程度量表及睡眠失功能信念及態度量表中譯版之信效度研究。台灣睡眠醫學會，台北榮民總醫院。

林詩維(民96)。失眠認知行為之療效與心理相關因素之改變。天主教輔仁大學心理學研究所碩士論文。未出版，台北縣。


二、英文部份

Ashton, H. (1994). Guidelines for rational use of benzodiazepine.When and what to use. Drug, 48(1), 25-40.

Baillargeon, L., Landreville, P., Verreault, R., Beauchemin, J. P., Gregoire, J. P., Morin, C. M.(2003). Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial. CMAJ, 169(10), 1015-1020.

Baldwin, A. S., Rothman, A. J., Hertel, A. W., Linde, J. A., Jeffery, R. W., Finch, E.A., & Lando, H.A. (2006). Specifying the determinants of the initiation and maintenance of behavior change: an examination of self-efficacy, satisfaction, and smoking cessation. Health Psychol, 25(5), 626-634.

Bandura, A. (1982). Self- efficacy mechanism in human agency. American Psychologist, 37, 122-147.

Belanger L., Morin, C. M., Bastien C., Ladouceur, R. (2005). Self-efficacy and compliance with benzodiazepine taper in older adults with chronic insomnia.
Health Psychology, 24(3), 281-287.
Belleville, G., Guay, C., Guay, B., Morin, C. M. (2007). Hypnotic taper with or without self-help treatment of insomnia: a randomized clinical trial. J Consult Clin Psychol, 75(2), 325-335.

Demmel, R., Nicolai, J., Jenko, D. M. (2006). Self-efficacy and alcohol relapse:
concurrent validity of confidence measures, self-other discrepancies, and prediction of treatment outcome. J Stud Alcohol, 67(4), 637-641.

DiCiemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velicer, W. F., Velasques, M. M., Rossi, J. S. (1991). The process of smoking cessation : An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59, 295-304.

Drake, C. L., Rohers, T., Roth, T. (2003). Insomnia causes, consequences, and therapeutics: an overview. Depression and Anxiety, 18, 163-167.

Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001a). Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. Jama, 285(14), 1856-1864.

Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001b). Does cognitive-behavioral insomnia therapy alter dysfunctional beliefs about sleep? Sleep, 24(5), 591-599.

Espie, C. A., Inglis, S. J., Harvey, L., & Tessier, S. (2000). Insomniacs' attributions. psychometric properties of the Dysfunctional Beliefs and Attitudes about Sleep Scale and the Sleep Disturbance Questionnaire. J Psychosom Res, 48(2), 141-148.

Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? Jama, 262(11), 1479-1484.

Gillin, J. C., Spinweber, C. L.,& Johnson, L. C. (1989). Rebound insomnia: a critical review. J Clin Psychopharmacol, 9(3), 161-172.

Gorgels, W. J., Oude Voshaar, R. C., Mol, A. J., van de Lisdonk, E. H., van Balkom, A. J., Breteler, M. H., et al. (2006). Predictors of discontinuation of benzodiazepine prescription after sending a letter to long-term benzodiazepine users in family practice. Fam Pract, 23(1), 65-72.

Harvey, A.G., Greenall, E. (2003). Catastrophic worry in primary insomnia. J Behav Ther Exp Psychiatry, 34(1), 11-23.

Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40, 869-894.

Janis, I. L. & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice and commitment. London: Cassel & Coolier Macmillan.

Kim, K., Uchiyama, M., Okawa, M., Liu, X., & Ogihara, R. (2000). An epidemiological study of insomnia among the Japanese general population. Sleep, 23(1), 41-47.

Kupfer, D .J., & Reynolds, C. F.(1997). Management of insomnia. N Engl J Med. 336(5), 341-346.

Lin, H. N. (2000).Pharmacotherapy of sleep disorder. Formosa J med, 4(6), 687-693.

Leger, D., Guilleminault, C., Bader, G.., Paillard, M. (2002). Medical and scoio - professional impact of insomnia. Sleep, 25, 625-629.

Morgan, K., Dixon, S., Mathers, N., Thompson, J., & Tomeny, M. (2003). Psychological treatment for insomnia in the management of long-term hypnotic drug use: a pragmatic randomised controlled trial. Br J Gen Pract, 53(497), 923-928.

Morin, C. M., Bastien, C., Guay, B., Radouco-Thomas, M., Leblanc, J., Vallières A. (2004). Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. Am J Psychiatry, 161(2), 332-342.
Morin, C. M., Belanger, L., Bastien, C., Vallieres, A. (2005).Long-term outcome after discontinuation of benzodiazepines for insomnia: a survival analysis of relapse.
Behavior Research Therapy. 43(1), 1-14.

Morin, C. M., Blais, F., & Savard, J. (2002). Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of insomnia? Behav Res Ther, 40(7), 741-752.

Morin, C. M., Colecchi, C., Stone, J., Sood, R. K., & Brink, D. (1999). Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. Jama, 281(11), 991-999.

Morin, C. M., Colecchi, C., Stone, J., Ling, W. D., & Sood, R. K. (1995). Cognitive behavior therapy to facilitate BZD discontinuation among hypnotic-dependent patients with insomnia. Behav ther, 26, 733-745.

Morin, C. M., Culbert, J. P. & Schwartz, S. M. (1994). Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry, 151(8), 1172-1180.

Morin, C. M., & Espie, C. A. (2003). Insomnia : a clinical guide to assessment and treatment. New York: Plenum Publishers.

Morin, C. M., Stone, J., Trinkle, D., Mercer, J., & Remsberg, S. (1993). Dysfunctional beliefs and attitudes about sleep among older adults with and without insomnia complaints. Psychol Aging, 8(3), 463-467.

Morin, C.M., Vallières, A., & Ivers, H. (2007). Dysfunctional beliefs and attitudes about sleep (DBAS): validation of a brief version (DBAS-16). Sleep. 30(11), 1547-1554.

Murtagh, D. R., & Greenwood, K. M. (1995). Identifying effective psychological
treatments for insomnia: a meta-analysis. J Consult Clin Psychol, 63(1), 79-89.

Nash, M. & Marcott, R. T. (1999). Using the transtheoretical model in guiding smoking cessation. The nurse Practioner, 24(2), 146-150.
Neubauer, D.N. (2003). Pharmacologic approaches for the treatment of chronic insomnia. Clin Cornerstone, 5(3), 16-27.

Nomura, K., Yamaoka, K., Nakao, M. & Yano, E. (2005). Impact of Insomnia on Individual Health Dissatisfaction in Japan, South Korea, and Taiwan. Sleep. 28(10), 1328-1332.

O'Connor, K. P., Belanger, Marchand, A. L., Mainguy, N., Dupuis, G., Elie, R. & Boyer, R. (1999). Psychological distress and adaptational problems associated with benzodiazepine withdrawal and outcome: a replication. Addiction Behavior, 24(4), 537-541.

O'Connor, K. P., Marchand, A., Belanger, L., Mainguy, N., Landry, P., Savard, P., Turcotte, J., Dupuis, G., Harel, F. & Lachance, L. (2004). Psychological distress and adaptational problems associated with benzodiazepine withdrawal and outcome: a replication. Addiction Behavior, 29(3), 583-593.

Ohayon, M. M. (2002). Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev, 6(2), 97-111.

O'Hea, E.L., Boudreaux, E. D., Jeffries, S. K., Carmack Taylor, C. L., Scarinci, I. C., (2004). Brantley PJ Stage of change movement across three health behaviors: the role of self-efficacy. Am J Health Promot, 19(2), 94-102.

Pallesen, S., Nordhus, I. H., Nielsen, G. H., Havik, O. E., Kvale, G.. & Johnsen, B. H., et al. (2001). Prevalence of insomnia in the adult Norwegian population. Sleep, 24(7), 771-779.
Palmeira , A. L., Teixeira, P. J., Branco, T. L., Martins, S. S., Minderico, C. S., Barata, J. T., Serpa, S. O. & Sardinha, L. B. (2007). Predicting short-term weight loss using four leading health behavior change theories. Int J Behav Nutr Phys Act , 20(4), xx-xx.
Parrino, L. & Terzano, M. (1996). Polysomnographic effects of hypnotic drugs. Psychopharmacology, 126(1), 1-16.

Prochaska , J. O. (1994). Strong and weak principles for processing from
precontemplation to action on the basis of twelve problem behaviors. Health
Psychology, 13, 47- 51.

Prochaska , J. O., Velicer, W. F., DiCiemente, C. C., Fava, J. (1988). Measuring
processes of change：Application to cessation of smoking. Journal of Consulting and Clinical Psychology, 56, 520-528.

Rickels, K., Case, W. G., Schweizer, E., Garcia-Espana, F. & Fridman, R. (1990). Benzodiazepine dependence：management of discontinuation. Psychopharmacol Bull, 26, 63-68.
Roach, J. B., Yadrick, M. K., Johnson, J. T., Boudreaux, L. J., Forsythe, W. A. & Billon W. (2003). Using self-efficacy to predict weight loss among young adults. J Am Diet Assoc, 103(10), 1357-1359.
Roehrs, T. & Roth, T. (2003). Hypnotics: an update. Curr Neurol Neurosci Rep , 3(2), 181-184.

Schneider-Helmert, D. (1988). Why low dose benzodiazepine -dependent insomniacs can't escape their sleep pills. Acta Psychiatritrica Scandinavica, 78, 706-711.

Schweizer, E., Case, W. G., & Rickels, K. (1989). Benzodiazepine dependence an withdrawal in elderly patient. Am J Psychiatry, 146, 529-531.

Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J. & Giles, D. E. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry, 159(1), 5-11.

Soldatos, C. R., Dikeos, D. G., & Whitehead, A. (1999). Tolerance and rebound insomnia with rapidly eliminated hypnotics: a meta-analysis of sleep laboratory studies. Int Clin Psychopharmacol, 14(5), 287-303.

Velicer, W. F., DiCiemente, C. C., Prochaska , J. O. & Brandenberg, N. (1985). Decision balance measure for assessing and predicting smoking status. Journal of personality and social psychology, 48, 1279-1289.

Velicer, W. F. & DiCiemente, C. C. (1990). Relapse situations and Self-efficacy: an integrative model. Addiction Behavior, 15, 271-283.

Vielva, I., Iraurgi, I. (2001). Cognitive and behavioural factors as predictors of
abstinence following treatment for alcohol dependence. Addiction, 96(2),
297-303.

Wamsteker, E. W., Geenen, R., Iestra, J., Larsen, J. K., Zelissen, P. M. & Staveren, W. A. (2005). Obesity-related beliefs predict weight loss after an 8-week low-calorie diet. J Am Diet Assoc, 105(3), 441-444.

Wiggers, L. C., Stalmeier, P. F., Oort, F. J., Smets, E. M., Legemate, D.A. & Haes, J. C. (2005). Do patients' preferences predict smoking cessation? Prev Med., 41(2), 667-675.

Woodward, M. (2000). Hypnotics: Options to help your patients stop. Aust Fam Physician, 29(10), 939-944.

Zammit, G.. K., Weiner, J., Damato, N., Sillup, G.. P., & McMillan, C.A. (1999). Quality of life in people with insomnia. Sleep, 22, S379 - S385.