強迫症門診患者的臨床特徵與聯合治療模式效果之分析研究

Clinical features and combination treatment outcomes of outpatients with obsessive-compulsive disorders

黃政昌(Cheng-Chang Huang)

指導教授 ： 林家興

國立臺灣師範大學/教育學院/教育心理與輔導學系/博士(2002年)

摘要

本研究以台灣地區的強迫症臨床樣本為研究對象，進行臨床特徵與聯合治療模式效果的分析研究。整個研究包括三個子研究，研究一目的在於描述強迫症患者的臨床特徵，包括人口學變項、求助經驗、臨床症狀與適應能力、病後人格等特徵與相互關係；研究二目的在驗證二種聯合治療模式的效果，進一步確認單一治療中，認知行為治療的效果是否優於藥物治療，而合併治療中，認知行為治療是否較可以助長藥物治療的效果，而藥物治療較不能助長認知行為治療改變；研究三目的則是針對強迫症患者進行訪談分析，以瞭解治療改變的歷程與改變的機制，並找出助長療效因子與抑制療效因子。
此三個研究分別使用不同的研究方法進行。研究一乃是針對北區某精神科專科醫院的強迫症的門診患者130位，以「門診患者基本資料表」、「高登人格量表（甲種）」、「耶魯布朗強迫症狀檢核表」、「耶魯布朗強迫症嚴重量表」、「簡式國際神經精神會談量表」、「生活品質量表」等六項工具，進行調查研究。研究二則邀請8位強迫症診患者為實驗對象，再將此8位受試者分成二組，每組4位分別進行不同治療順序的「跨受試延宕多基準線設計」之單一受試實驗，並以「耶魯布朗強迫症嚴重量表」來評估強迫症各種治療方式的效果改變。研究三則以參加完研究二的8位實驗對象繼續為受訪者，配合半結構式的訪談指引，進行質性方法的深度訪談。研究結果與發現如下：
1.男性在「性」和「精確」強迫思考上的人數百分比都顯著的高於女性。未婚者在「性」強迫思考的人數百分比顯著的高於已婚者；年齡愈低者愈容易出現「性」強迫思考。無職業者在「清洗」強迫行為上的人數百分比顯著的高於有職業者。教育程度愈低者，愈容易出現「清洗」的強迫行為；教育程度愈高者愈容易出現「計算」的強迫行為；「強迫症數量和共病數目」可以有效預測強迫症嚴重度、生活品質與病後人格。
2.第1類聯合治療模式與第2類聯合治療模式均有顯著治療效果。且單一治療時：認知行為治療的效果優於藥物治療；合併治療時，認知行為治療對藥物治療增進效果，較藥物治療對認知行為治療的增進效果明顯。
3.改變較明顯組的助長療效因子與改變較不明顯組的抑制療效因子，主要反應在症狀因素、個人因素、家庭因素、社會因素、藥物治療效果、認知行為治療效果等五方面的「程度」上差異，其中，積極參與認知行為治療的程度、個人配合相關治療的能力，以及家庭因素對個案支持與接納程度，是改變機制發生的核心因素。
根據研究結果與討論，研究者提出未來研究、臨床實務、心理衛教等三方面的建議。本研究一方面可充實國內強迫症文獻的基礎，二方面亦可作為日後臨床實務上治療強迫症的參考資料。

關鍵字

強迫症 ； 臨床特徵 ； 聯合治療模式 ； 認知行為治療 ； 藥物治療 ； 治療效果 ； 改變歷程 ； 改變機制

並列摘要

The overall purpose of this project was to survey clinical features and to analyze the effectiveness of two combination treatment models for outpatients with obsessive-compulsive disorders(OCD). Three studies under this project had been carried out. The aim of the first study was to survey clinical features, including demographic variables, clinical symptoms, help-seeking experience, adaptive abilities, and personality after onset. The aim of the second study was to examine the differential therapeutic effects of two combination treatment models. Specifically, the investigator intended to further confirm previous research finding whether cognitive-behavior therapy(CBT) was more effective than drug treatments(SSRIs) in the single treatment of OCD, and whether the effects of CBT were more powerful to facilitate the effects of the SSRIs than the effects of SSRIs do to the effects of CBT in the combination treatments of OCD. The purpose of the third study was to explore the change process, the facilitating factors, and the inhibiting factors in the change mechanisms.
A total of 130 OCD outpatients participated in study one. In order obtain the information on clinical features, all participant were invited to complete a set of inventories, including Gordon Personal Profile, Yale-Brown Obsessive-Compulsive Scale(symptom checklist), Yale-Brown Obsessive-Compulsive Scale(symptom severity), Mini International Neuropsychiatric Interview(MINI), and the Quality of Life Assessment(WHOQOL). A delayed multiple baseline across individuals design was adopted in conducting study two. There were 8 OCD outpatients were recruited as subjects in this study. A group of four were assigned to one of the two systematic combination treatment models. Subjects’ treatment responses measured by the Yale-Brown Obsessive-Compulsive Scale (symptom severity)” were collected each week throughout the course of treatment. The same 8 participants in study two were recruited as the subjects in study three. They were invited to participate in an in-depth interview after the course of their combination treatments.
The results of the research were as follows:
1.Among the research participants, men, compared to women, appeared more sexual and symmetry/exactness obsessions. Single, compared to married, appeared more sexual obsessions. Younger OCD outpatients appeared more sexual obsessions than those of elder. Unemployed, compared to employed status, appeared more washing compulsions. OCD outpatients with higher level of educational background appeared more counting compulsions than those with lower level of educational background. Symptom numbers and comorbidity numbers were the most effective factors in predicting obsessive-compulsive severity, quality of life, and personality after onset.
2.There were significant effects were found in both of the two combination treatment models. Further findings verified that cognitive-behavior therapy (CBT) was more effective than drug treatments (SSRIs) in single treatment of OCD, and the effects of CBT were more powerful to facilitate the effects of SSRIs than the effects of SSRIs to facilitate the effects of CBT in combination treatments of OCD.
3.The treatment outcome facilitating factors found between the most gained treatment group and the least gained treatment group were: personal factors, family factors, social factors, drug treatment, and CBT treatment. The three core facilitating factors found in this study were: active CBT participation, personal motivation and ability, and family acceptance and support.
In addition, the research and treatment implications of the findings and suggestions for future research and clinical practice were also discussed in this study.

並列關鍵字

obsessive-compulsive disorder ； clinical features ； the combination treatment model ； cognitive-behavior therapy (CBT) ； drug treatments (SSRIs) ； treatment effects ； change process ； change mechanism

參考文獻

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商志雍、林信男（2002）。精神疾病藥物治療病案討論(15)--強迫症之藥物治療策略。當代醫學，29（3），194-195。

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