【作者】 邓公平；

【导师】 李宜雄；

【作者基本信息】 中南大学 ， 临床医学， 2013， 博士

【摘要】 第一部分负性情绪筛查以及消极认知偏差测查工具在胰腺癌患者中的应用目的：探讨负性情绪筛查以及消极认知偏差测查工具在胰腺癌患者中的适用性,并比较胰腺癌患者与社区正常对照组在情绪以及负性认知中的特征。方法：选择2009年7月至2011年12月期间在湖南5所三甲医院选取胰腺癌共1029人,男性545例,女性484例,以及472名社区对照者完成以下3个量表：心境与焦虑症状问卷简式(MASQ-SF),认知失调性态度问卷(DAS)与认知方式问卷(CSQ)。采用下列方法检验认知情绪调节问卷的信度：(1) Cronbach a系数：主要检验量表的同质性信度。(2)条目间平均相关系数(mean inter-term correlation):通过计算总量表、各分量表的条目间两两相关的均值,检验量表的同质性。(3)：重测信度：主要检验量表的跨时间的稳定性。效度检验包括结构效度(验证性因素分析)以及聚合与区分效度。采用t检验比较两组样本在焦虑抑郁的情绪问题中的区别以及负性认知偏差的特征。采用量表间的相关评估CERQ-C的聚合与区分效度。采用独立样本t检验比较胰腺癌患者的负性情绪问题以及消极偏差特征的性别差异。结果：(1)量表得分情况：胰腺癌患者组与社区对照组得分在负性情绪的各个因子均有显著差异,并且胰腺癌患者有更多的消极的功能失调性态度。而男女患者在负性情绪总分及各因子得分上均无显著差异,但是胰腺癌患者在消极认知偏差的因素中受试者得分具有显著的性别差异。(2)信度：胰腺癌患者组：(1)心境与焦虑症状问卷的总量表的内部一致性系数α=0.88,各量表α系数在0.79-0.93之间。(2)功能失调性态度问卷的内部一致性系数为α=0.75；(3)认知方式问卷的内部一致性系数为α=0.79。社区对照组：(1)心境与焦虑症状问卷的总量表的内部一致性系数α=0.88,(2)功能失调性态度问卷的内部一致性系数为α=0.79,(3)认知方式问卷的内部一致性系数为α=0.80。(2)条目间平均相关系数：胰腺癌患者组：心境与焦虑症状问卷的总量表的条目间平均相关系数为0.29,功能失调性态度问卷的总量表条目间平均相关为0.33,而认知方式问卷的总量表条目平均相关系数为0.33,社区对照组：心境与焦虑症状问卷的总量表的条目间平均相关系数为0.31,而功能失调性态度问卷的总量表条目间平均相关为0.31,而认知方式问卷的总量表条目平均相关系数为0.29。重测信度：胰腺癌患者组：心境与焦虑症状问卷的总量表的1.5个月的重测信度为0.80,功能失调性态度问卷的重测信度为0.72,而认知方式问卷的重测信度为0.66。社区对照组：心境与焦虑症状问卷的总量表的1.5个月的重测信度为0.71,功能失调性态度问卷的重测信度为0.71,而认知方式问卷的重测信度为0.71.(3)结构效度：验证性因素分析结果显示,在胰腺癌患者样本以及社区对照组样本中,心境与焦虑症状问卷的模型的拟合指数良好：拟合指数；X2/df分别为2.19和2.83,均接近2并小于5；CFI、IFI、TLI均大于0.90；RMSEA均小于等于0.08。在胰腺癌患者样本以及社区对照组样本中认知方式问卷的模型的拟合指数良好：拟合指数；X2/df分别为2.22和3.91,均接近2并小于5；CFI、IFI、TLI均大于0.90；RMSEA均小于等于0.08。聚合与区分效度：心境与焦虑症状问卷以及认知方式问卷各分量表间及与总量表间的相关分析,各分量表间及各分量表与总量表的相关性,如表2-6所示,胰腺癌患者组的分量表与总量表之间的相关系数以及分量表之间的相关系数均有显著性意义,而社区对照组的分量表与整个量表之间的相关系数以及各个分量表间的相关系数均有显著性意义。结论：负性情绪筛查工具以及消极认知偏差测评工具在胰腺癌患者中,显示了良好的信、效度,可以协助评价胰腺癌患者的情绪问题以及消极认知偏差问题,对胰腺癌患者的治疗与护理提供新的思路与理论依据第二部分认知高风险胰腺癌患者心理特征以及临床症状特征目的：探讨高低风险的胰腺癌患者心理特征以及初步探讨其临床症状的特点,以期从心理病理学角度了解胰腺癌患者的心理与生理症犬的发生机制。并用数理建模的方法构建心理因素影响心身症状的机制。方法：从参与第一部分的胰腺癌患者中根据认知高风险个体筛选示准筛选出认知高风险胰腺癌患者共129名患者,而同时选择在两个司卷中均得分后25%的患者作为认知低风险的胰腺癌患者作为比较,共159人。被试按照每个心理测评量表的标准指导语完成以下量表：生活质量综合评定问卷(Generic Quality of Life nventory-74,GQOLI-74);医院焦虑抑郁量表(The Hospital Anxiety md Depression Scale, HAD);认知失调性态度问卷(Dysfunctional Attitude Scale, DAS);心境与焦虑症状问卷简式(Mood and Anxiety ymptom Questionnaire-Short Form, MASQ-SF);认知方式问卷(Cognitive Style Questionnaire,CSQ)。以及患者疼痛分级程度评估法(NRS)评估胰腺癌患者的疼痛体验。计量资料采用均数±标准差,两组间比较用t检验,两组以上组间比较用方差分析。结构方程的建模采用AMOS6.0版本完成。结果：两组受试者得分在情绪状况得分中均具有显著差异,认知高风险组胰腺癌患者有更多的总体的负性情绪问题,并在焦虑,抑郁的各个分量表中也显著高于低认知风险组的个体。高认知风险胰腺癌患者在功能失调性态度的大部分分量表得分均高于低认知风险的胰腺癌患者组,且均具有显著性差异(P<.05)。两组受试者在对自身,对负性生活事件发生的理解以及对未来的期望等方面的得分均具有显著差异。高认知风险胰腺癌患者在认知方式的各个分量表得分均高于低认知风险的胰腺癌患者组,且均具有显著性差异.各个分量表分别与抑郁症状呈显著正相关；而功能失调性态度以及自身稳定性归因与疼痛得分显著正相关。而在控制其他分量表影响后,功能失调性态度以及自我归因仍与抑郁,焦虑症状呈显著正性相关(均P<0.05),而控制其他分量表影响后,功能失调性态度总分仍与疼痛得分显著正相关。为进一步验证消极认知策略对焦虑和抑郁症状以及胰腺癌患者疼痛的预测作用,采用多元回归分析来评估功能失调性态度以及认知方式策略与抑郁和焦虑症状以及胰腺癌疼痛的关系,第一步性别进入回归方程,第二步不同的认知策略同时进入回归方程。多元回归分析的结果提示,排除性别差异,功能失调性态度可以独立预测抑郁与焦虑症状的发生。而胰腺癌患者在应对胰腺癌的打击时,使用以下策略越多,抑郁和焦虑症状也越多：功能失调性态度,自我归因以及持久的归因等。而在验证消极认知策略对疼痛的预测中,,采用多元回归分析来评估功能失调性态度以及认知方式策略与胰腺癌疼痛的关系,第一步性别进入回归方程,第二步不同的认知策略同时进入回归方程。结果发现,功能失调性态度可以独立影响疼痛的程度,而具有持久性归因的患者,其疼痛的程度也更大。本研究采用了结构方程模型建立策略,先根据理论假说设定多个模型,通过模型比较得到一个统计上可以接受,合符理论依据的相对有效和节俭的模型。结果发现模型2的模型拟合最佳,卡方值最小,并且X2/df(2.463)和RMSEA(0.068)均小于模型1,而CFI(0.93)、IFI (0.92)和GFI(0.94)均大于模型1,且理论支持充分,所以,模型2为最佳模型。消极认知策略影响患者的对疾病的态度以及观念,从而影响患者的情绪以及疼痛体验。即消极认知策略对胰腺癌病人情绪以及生理性疼痛的影响不是通过直接效应,而是通过间接效应,即消极认知策略是通过功能失调性态度这个中介变量作用,并影响了患者情绪以及疼痛的状况。结论：消极认知偏差高风险的胰腺癌患者有更多的情绪问题,生活质量问题,以及更严重的癌性疼痛的体验。更多还原

【Abstract】 Part Ⅰ The application of Negative emotions and negative screening test of cognitive bias search tool in pancreatic cancer patientsObjective:The aim of the present study was to study the applicability of negative emotions and negative screening test of cognitive bias tool in the patients with pancreatic cancer and to compare the pancreatic cancer patients with community control group in the emotional and negative cognitive features.Methods:This study included1029patients and472normative subjects. All of the subjects completed the Chinese version of the Mood and Anxiety Symptom Questionnaire-Short Form,(MASQ-SF); Dysfunctional Attitude Scale,(DAS) and Cognitive Style Questionnaire (CSQ). We calculated the mean inter-item correlations for the total Scale and for each of the subscales. Cronbach’s alpha coefficients to analyze the inter-correlations and reliability. We utilized confirmatory factor analysis to do measurement model A one-way multivariate analysis of variance (MANOVA) was computed to examine the effects of gender.Results:(1) Scale scores:negative emotion scores in patients with pancreatic cancer group and the community control group were significantly different in all factors and pancreatic cancer patients have more negative dysfunctional attitudes. Negative emotion score in Male and female patients and factor scores were not significantly different, but the negative cognitive bias the pancreatic cancer patients in factor score of the subjects had significant gender differences.(2) Reliability:The pancreatic cancer group:(1) the total scale’s internal consistency coefficient of mood and anxiety symptoms questionnaire is0.88, and all subscales between0.79to0.93.(2) Dysfunctional attitude questionnaire: internal consistency coefficient (a=0.75);(3) internal consistency coefficient for cognitive style questionnaire is0.79. Community control group:(1) total scale internal consistency coefficient for mood and anxiety symptoms questionnaire is0.88,(2) internal consistency coefficient of Dysfunctional attitude questionnaire is0.79,(3) The internal consistency coefficient for Cognitive Style Questionnaire is0.80(2) The average correlation coefficient between items:pancreatic cancer group:mood and anxiety symptom questionnaire entries in the table between the total amount of the average correlation coefficient is0.29, the average correlation for the total scale of dysfunctional attitudes questionnaire was0.33and the total amount of the average correlation coefficient for the cognition Style Questionnaire was0.33. The community control group:the total amount of the correlation coefficient for the mood and anxiety symptom questionnaire is0.31, while the Dysfunctional Attitude average correlation between the total table entries0.31, while the cognitive style questionnaire table entry total average correlation coefficient is0.29.(3) Construct validity:confirmatory factor analysis showed that samples of pancreatic cancer patients and the community in the control group sample have a good model fit index of mood and anxiety symptoms questionnaire. The convergent and discriminant validity:The correlation between subscales and total scale of mood and anxiety symptom questionnaire and the cognitive style questionnaire ient between the correlation coefficients between subscales were significant.Conclusion:Negative emotions-and negative cognitive bias screening tool assessment tool in pancreatic cancer patients, showed good reliability and validity, can assist in evaluating the emotional problems of patients with pancreatic cancer and negative cognitive bias problem, to provide new ideas in pancreatic cancer patients Treatment and care. Part I The use of the Cognitive Emotion Regulation Questionnaire Chinese Version (CERQ-C) in a hypertensive subjectObjective:The aim of the present study was to develop a Chinese version of the Cognitive Emotion Regulation Questionnaire (CERQ-C) and to examine its psychometric properties in both hypertensive and normative subjects.Methods:This study included434hypertensive patients and462normative subjects. All of the subjects completed the Chinese version of the Cognitive Emotion Regulation Questionnaire,(CERQ); Dysfunctional Attitude Scale,(DAS); Mood and Anxiety Symptom Questionnaire Short Form,(MASQ-SF); Center for Epidemiologic Studies Depression Scale,(CES-D). We calculated the mean inter-item correlations for the total CERQ-C and for each of the subscales. Cronbach’s alpha coefficients to analyze the inter-correlations and reliability. When examining the nine-factor model, we utilized confirmatory factor analysis. The measurement model consisted of nine first-order factors (self-blame, acceptance, rumination, positive refocus, refocus on planning, positive reappraisal, putting into perspective, catastrophizing, and blaming others). A one-way multivariate analysis of variance (MANOVA) was computed to examine the effects of gender. Results:(1) The Cognitive Emotion Regulation strategies hypertension patients and normative sample most frequently used were positive reappraisal. Hypertensive group reported significantly higher scores than normative sample on Rumination (12.19±2.51/11.51±2.60,p<0.001) and catastrophizing (8.82±2.19/8.11±2.70, p<0.001), blaming others (10.76±2.11/9.88±2.48, p<0.001) and significantly lower scores than normative sample on positive reappraisal (13.80±3.55/14.71±4.11,p<0.001)(2)reliability:In hypertension group the Cronbach’s alpha for the Total CERQ-C was0.80, and the Cronbach’s alpha coefficient for the nine subscale ranged from0.71(Self-blame) to0.90(Rumination). And in normative group the Cronbach’s alpha for the Total CERQ-C was0.79, and the Cronbach’s alpha coefficient for the nine subscale ranged from0.71(Positive Reappraisal) to0.90(Rumination). The mean inter-item correlation coefficient for the nine subscale ranged from0.21-0.42(hypertension group)/0.19-0.32(normative group). In hypertension group, the test-retest reliability of the total scale was0.82, the test-retest reliability of nine subscales ranged from0.73to0.92; And in normative group, the test-retest reliability of the total scale was0.79, the test-retest reliability of nine subscales ranged from0.71to0.88.(3) Confirmatory factor analysis:The results of our CFA suggest that the nine first-order factors data fit the both two sample well.(X2/(df)=2.28, p<0.001,CFI=0.91, IFI=0.92, RMSEA=0.05, TLI=0.944)/(x2/(df)=2.34, p<0.001,CFI=0.91, IFI=0.91, RMSEA= 0.08, TLI=0.90).(4):Convergent and discriminate validity:In hypertensive group Self-blame(y=0.14, p<0.01), catastrophizing (y=0.55, p<0.001), blaming others (γ=0.47,p<0.001) were positively correlated with the total scores of Dysfunctional Attitude Scale. And Positive Refocusing (t=-0.21, p<0.01), Putting into Perspective (y=-0.27,p<0.01) were negatively correlated with the total scores of Dysfunctional Attitude Scale. In normal group, Self-blame(y=0.37, p<0.001), Rumination (t=0.61, p<0.001), catastrophizing (γ=0.67, p<0.001), blaming others (γ=0.49, p<0.001) were positively correlated with the total scores of Dysfunctional Attitude Scale. Refocus on Planning (y=-0.27,p<0.001), Putting into Perspective (t=-0.33,p<0.001) were negatively correlated with the total scores of dysfunctional Attitude Scale.Conclusion:The properties of CERQ-C met the psychometrics standard indicated that it is a reliable and valid assessment of cognitive emotion regulation strategies, and can be considered as an appropriate tool for assessing Part2Study on the Cognitive Emotion Regulation strategies of the hypertension patients with depressionObjective:We study on the cognitive emotion regulation strategies and dysfunctional attitudes of the hypertension patients with or with not depression. Following a psychosocial perspective to study in the onset of depression.Methods:Recruiting1400hypertensive patients with depression from those patients recorded in the "Family Home of Hypertensive patients" and the out-patients with essential hypertension. Screening hypertension sufferers with the Hospital Anxiety and Depression Scale (HAD), the subjects with positive results (HAD>9) were evaluated with HAMA and HAMD.250patients enter the hypertension with depression group from263patients with positive screened result (HAMD>20, HAMA<14). And250hypertension patients with no depression as member of hypertension with no depression group.462normative subjects as member of normative group. All of the them completed the Hospital Anxiety and Depression Scale,(HAD), Cognitive Emotion Regulation Questionnaire,(CERQ), Dysfunctional Attitude Scale,(DAS)、Hamilton Anxiety Scale,(HAMA), Hamilton Depression Scale,(HAMD).Results:Significant differences were found in the use of Cognitive Emotion Regulation strategies between the three group (Wilks’ Lambda=0.79, P=0.001, Hotelling’s Trace=0.04, P=0.001).On the Self-blame, Positive Reappraisal, normative group reported significantly highest scores, hypertension with no depression group ranked second, and hypertension with depression group reported significantly lowest score. On Acceptance, Refocus on Planning factors, lower in hypertension with depression group than normative group and higher than hypertension with no depression group. On Rumination and Catastrophizing factors, lower in normative group than hypertension with depression group and higher than hypertension with no depression group. On Positive Refocusing, lower in normative group than hypertension with no depression group and higher than hypertension with depression group. On Putting into Perspective, lower in hypertension with depression group than hypertension with no depression group and higher than normative group. On the Blaming Others factor, lower in hypertension with no depression group than hypertension with depression group and higher than normative group. Significant differences were also found in the dysfunctional attitude between the three group.(Wilks’ Lambda=0.67, P=0.001, Hotelling’s Trace=0.05, P=0.001)A comparison among the two competitive models using SEM showed that the model-2was the optimal model, with better fit indexes than the others (X2/df (1.882), RMSEA (0.063), CFI (0.932), IFI (0.911), GFI (0.921)), and with the most parsimonious path(p<0.01).Conclusion:Patients of hypertension with depression more use Rumination, Catastrophizing and blame others et al negative Cognitive Emotion Regulation strategies and exists dysfunctional attitudes. Part3The effect of Antidepressant and Psychological Intervention on the Quality of Life and Blood Pressure of Hypertensive Patients with DepressionObjective:The effects of antidepressant and psychological intervention on the blood pressure and quality of life in hypertension patients with depression were investigatedMethods:After evaluating1400patients with essential hypertension by Hospital Anxiety and Depression Scale (HAD), patients with HAD positive result were evaluated with Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA). The subjects with positive results with HAMD were randomly divided into antidepressant and psychological intervention group (n=30, routine treatment, mental state intervention and the usage of antidepressant(seroxat)) and control group (n=30, only routine treatment).The effect of blood pressure control, the quality of life and the level of depression were compared between2groups.Results The depression symptoms were significantly improved in antidepressant and psychological intervention group compared to control group. The HAMD score fell from30.03±1.83at time of entrance to17.43±1.96at time of the study end; The blood pressure control were more effective with antidepressant and psychological intervention, The mean SBP and DBP decreased by26.17mmHg and13.63mmHg in antidepressant and psychological intervention group, while there were only14.32mmHg and7.18mmHg decrease in SBP and DBP respectively in control group; And the antidepressant and psychological intervention group have higher score quality of life. The total score of GQOLI-74has risen from65.97±4.68before treatment to71.20±5.13after treatment.Conclusion:The treatment of psychological intervention and usage of antidepressant could improve the control of blood pressure and quality of life in hypertensive patients.更多还原