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題名 探討CBT-I結合心跳變異率生理回饋介入失眠疾患之療效
Treatment efficacy of CBT-I combined with HRV Biofeedback for insomnia disorder
作者 林允凱
Lin, Yun-Kai
貢獻者 楊建銘
Yang, Chien-Ming
林允凱
Lin, Yun-Kai
關鍵詞 失眠認知行為治療
心跳變異率生理回饋
自我效能
依從性
隨機分派臨床試驗
Cognitive behavioral therapy for insomnia
Heart rate variability biofeedback
Self-efficacy
Adherence
Randomized clinical trial
日期 2023
上傳時間 9-Mar-2023 18:24:47 (UTC+8)
摘要 研究背景與目的：失眠認知行為治療 (cognitive behavioral therapy [CBT-I]) 被證實能有效改善失眠，但研究顯示仍有部分患者沒有良好的療效反應。本研究以提升CBT-I療效為目標，探討以下問題：(1) 失眠患者具有自主神經系統 (autonomic nervous system [ANS]) 過度激發的現象，但目前CBT-I中較缺乏直接針對改善ANS的介入成分，故本研究欲探討CBT-I結合以訓練ANS功能為目標的心跳變異率生理回饋 (heart rate variability biofeedback [HRV-BF]) 在失眠疾患上的療效。(2) 過往研究指出CBT-I治療依從性及睡眠自我效能可以預測患者的失眠嚴重度，但目前研究較少探討睡眠自我效能與依從性兩者的關聯性，因此，本研究欲針對睡眠自我效能、治療依從性與失眠嚴重度三者的關聯性作進一步探討。

研究方法：本研究將37位失眠患者隨機分派到CBT-I組 (CBT-I，N = 18) 或結合CBT-I與HRV-BF (CBT-I+BF，N = 19) 的組別，接受七週的個別治療，在治療前後測量失眠嚴重度、睡前激發狀態、睡眠自我效能及其他睡眠參數與生理指標，並治療後三個月追蹤的失眠嚴重度及睡眠自我效能。本研究以CBT-I行為技術執行程度及治療師主觀評分為依從性指標，並分析其與睡眠自我效能及失眠嚴重度的關聯性。

研究結果：兩組的失眠嚴重度及多數睡眠參數在治療後皆有顯著改善，且其改善的程度並無顯著差異，而CBT-I+BF組在三個月追蹤有較高的失眠緩解率，且後測有更佳的自主神經功能平衡指標，而其餘療效指標則沒有顯著組間差異。睡眠自我效能、治療依從性與失眠嚴重度三者有顯著正相關，而階層迴歸分析顯示睡眠自我效能對治療師評分依從性及失眠嚴重度改變量有顯著解釋力，而治療師評分依從性對失眠嚴重度改變量也有顯著解釋力。

結論：本研究發現結合HRV-BF的方案與標準CBT-I有相同程度的治療效果，而前者在治療後能帶來更好的自主神經功能表現，且顯示出較好療效維持趨勢。後續研究應進一步探討適合此治療方案的失眠患者可能具有的特性。此外，在CBT-I治療過程中，治療師也應更多關注患者的自我效能提升，藉此促進更好的治療效果。
Objectives: Although the effect of cognitive behavioral therapy for insomnia (CBTI) has been well documented, there is still room for improvement given that some patients do not respond well to the treatment. The current study aims to improve the efficacy of CBT-I with the following objectives: (1) Since the skills of CBT-I do not target directly on reducing patients’ autonomic nervous system (ANS) hyperarousal, the current study aims to exam whether combining CBT-I with heart rate variability biofeedback (HRV-BF) to reduce ANS arousal can enhance the treatment effect. (2) Previous studies suggested that CBT-I treatment adherence and self-efficacy of sleep could predict post-treatment insomnia severity, but the relationship between self-efficacy of sleep and adherence has not been well studied. Therefore, the current study try to explore the relationship between self-efficacy of sleep, adherence, and insomnia severity.

Method: 37 patients with insomnia disorder were randomly assigned to a CBT-I group (N = 18), in which participants received seven sessions of CBT-I treatment, or a CBT-I+BF group (N = 19), in which participants received CBT-I combined with HRV-BF. Participants completed a package of self-rating scales, including Insomnia Severity Index (ISI), Pre-Sleep Arousal Scale (PSAS), and Self-efficacy of Sleep scale (SE-S) at baseline, in-treatment, and post-treatment. ISI and SE-S were also measure at 3-month follow-up. Pittsburgh Sleep Quality Index (PSQI), sleep parameters derived from patient-reported sleep diary, and HRV indicators were measured at baseline and post treatment. Treatment adherence was rated by therapist weekly according to the particiapnts’ degree of homework completion, and measured by adherence to behavioral strategies (ABS) derived from patient-reported sleep diary. The correlation between treatment adherence, SE-S, and ISI was examined.

Results: Both groups showed significant improvement on all self-report scales and most sleep parameters after treatment. No significant group differences were found. CBT-I+BF showed significantly better ANS function balance at post-treatment, and a higher remission rate (ISI<8) at 3-month follow-up. SE-S, treatment adherence, and changes in ISI were positively correlated. SE-S predicted greater therapist-rated adherence as well as greater ISI reduction from baseline to post-treatment, while therapist-rated adherence also predicted greater ISI reduction from baseline to post-treatment.

Conclusions: Both CBT-I alone and CBT-I combining with HRV-BF showed promising treatment effect, while the combined treatment showed better ANS improvement and better treatment effect maintenance. Future studies should further investigate the characteristics of patients that can be use to identfify those patients who may benefit from the combined treatment. In addition, CBT-I therapists should pay more attention to enhance patients` self-efficacy to promote better CBT-I treatment effects.
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描述 碩士
國立政治大學
心理學系
108752021
資料來源 http://thesis.lib.nccu.edu.tw/record/#G0108752021
資料類型 thesis
dc.contributor.advisor 楊建銘zh_TW
dc.contributor.advisor Yang, Chien-Mingen_US
dc.contributor.author (Authors) 林允凱zh_TW
dc.contributor.author (Authors) Lin, Yun-Kaien_US
dc.creator (作者) 林允凱zh_TW
dc.creator (作者) Lin, Yun-Kaien_US
dc.date (日期) 2023en_US
dc.date.accessioned 9-Mar-2023 18:24:47 (UTC+8)-
dc.date.available 9-Mar-2023 18:24:47 (UTC+8)-
dc.date.issued (上傳時間) 9-Mar-2023 18:24:47 (UTC+8)-
dc.identifier (Other Identifiers) G0108752021en_US
dc.identifier.uri (URI) http://nccur.lib.nccu.edu.tw/handle/140.119/143780-
dc.description (描述) 碩士zh_TW
dc.description (描述) 國立政治大學zh_TW
dc.description (描述) 心理學系zh_TW
dc.description (描述) 108752021zh_TW
dc.description.abstract (摘要) 研究背景與目的：失眠認知行為治療 (cognitive behavioral therapy [CBT-I]) 被證實能有效改善失眠，但研究顯示仍有部分患者沒有良好的療效反應。本研究以提升CBT-I療效為目標，探討以下問題：(1) 失眠患者具有自主神經系統 (autonomic nervous system [ANS]) 過度激發的現象，但目前CBT-I中較缺乏直接針對改善ANS的介入成分，故本研究欲探討CBT-I結合以訓練ANS功能為目標的心跳變異率生理回饋 (heart rate variability biofeedback [HRV-BF]) 在失眠疾患上的療效。(2) 過往研究指出CBT-I治療依從性及睡眠自我效能可以預測患者的失眠嚴重度，但目前研究較少探討睡眠自我效能與依從性兩者的關聯性，因此，本研究欲針對睡眠自我效能、治療依從性與失眠嚴重度三者的關聯性作進一步探討。

研究方法：本研究將37位失眠患者隨機分派到CBT-I組 (CBT-I，N = 18) 或結合CBT-I與HRV-BF (CBT-I+BF，N = 19) 的組別，接受七週的個別治療，在治療前後測量失眠嚴重度、睡前激發狀態、睡眠自我效能及其他睡眠參數與生理指標，並治療後三個月追蹤的失眠嚴重度及睡眠自我效能。本研究以CBT-I行為技術執行程度及治療師主觀評分為依從性指標，並分析其與睡眠自我效能及失眠嚴重度的關聯性。

研究結果：兩組的失眠嚴重度及多數睡眠參數在治療後皆有顯著改善，且其改善的程度並無顯著差異，而CBT-I+BF組在三個月追蹤有較高的失眠緩解率，且後測有更佳的自主神經功能平衡指標，而其餘療效指標則沒有顯著組間差異。睡眠自我效能、治療依從性與失眠嚴重度三者有顯著正相關，而階層迴歸分析顯示睡眠自我效能對治療師評分依從性及失眠嚴重度改變量有顯著解釋力，而治療師評分依從性對失眠嚴重度改變量也有顯著解釋力。

結論：本研究發現結合HRV-BF的方案與標準CBT-I有相同程度的治療效果，而前者在治療後能帶來更好的自主神經功能表現，且顯示出較好療效維持趨勢。後續研究應進一步探討適合此治療方案的失眠患者可能具有的特性。此外，在CBT-I治療過程中，治療師也應更多關注患者的自我效能提升，藉此促進更好的治療效果。		zh_TW
dc.description.abstract (摘要) Objectives: Although the effect of cognitive behavioral therapy for insomnia (CBTI) has been well documented, there is still room for improvement given that some patients do not respond well to the treatment. The current study aims to improve the efficacy of CBT-I with the following objectives: (1) Since the skills of CBT-I do not target directly on reducing patients’ autonomic nervous system (ANS) hyperarousal, the current study aims to exam whether combining CBT-I with heart rate variability biofeedback (HRV-BF) to reduce ANS arousal can enhance the treatment effect. (2) Previous studies suggested that CBT-I treatment adherence and self-efficacy of sleep could predict post-treatment insomnia severity, but the relationship between self-efficacy of sleep and adherence has not been well studied. Therefore, the current study try to explore the relationship between self-efficacy of sleep, adherence, and insomnia severity.

Method: 37 patients with insomnia disorder were randomly assigned to a CBT-I group (N = 18), in which participants received seven sessions of CBT-I treatment, or a CBT-I+BF group (N = 19), in which participants received CBT-I combined with HRV-BF. Participants completed a package of self-rating scales, including Insomnia Severity Index (ISI), Pre-Sleep Arousal Scale (PSAS), and Self-efficacy of Sleep scale (SE-S) at baseline, in-treatment, and post-treatment. ISI and SE-S were also measure at 3-month follow-up. Pittsburgh Sleep Quality Index (PSQI), sleep parameters derived from patient-reported sleep diary, and HRV indicators were measured at baseline and post treatment. Treatment adherence was rated by therapist weekly according to the particiapnts’ degree of homework completion, and measured by adherence to behavioral strategies (ABS) derived from patient-reported sleep diary. The correlation between treatment adherence, SE-S, and ISI was examined.

Results: Both groups showed significant improvement on all self-report scales and most sleep parameters after treatment. No significant group differences were found. CBT-I+BF showed significantly better ANS function balance at post-treatment, and a higher remission rate (ISI<8) at 3-month follow-up. SE-S, treatment adherence, and changes in ISI were positively correlated. SE-S predicted greater therapist-rated adherence as well as greater ISI reduction from baseline to post-treatment, while therapist-rated adherence also predicted greater ISI reduction from baseline to post-treatment.

Conclusions: Both CBT-I alone and CBT-I combining with HRV-BF showed promising treatment effect, while the combined treatment showed better ANS improvement and better treatment effect maintenance. Future studies should further investigate the characteristics of patients that can be use to identfify those patients who may benefit from the combined treatment. In addition, CBT-I therapists should pay more attention to enhance patients` self-efficacy to promote better CBT-I treatment effects.		en_US
dc.description.tableofcontents 第一章、緒論 1
第二章、文獻探討 4
第一節、失眠的定義與流行病學研究 4
第二節、失眠的相關病理機制 5
一、Spielman三因子模式 5
二、失眠的認知模式及神經認知觀點 6
三、失眠的過度激發理論 8
四、神經行為病因模式 10
五、小結 11
第三節、失眠認知行為治療 11
一、CBT-I治療技術 11
二、CBT-I之療效研究 13
三、CBT-I的限制與改善空間 14
四、小結 16
第四節、生理回饋 16
一、生理回饋之療效解釋模式 17
1.控制論及自主神經系統之操作制約學習 17
2.自我效能模式 18
二、生理回饋介入失眠疾患之相關研究 20
三、小結 25
第五節、CBT-I治療機制的心理及行為因子 27
一、治療依從性與失眠嚴重度之關聯性 27
二、自我效能感與失眠嚴重度之關聯性 28
三、自我效能感與治療依從性之關聯性 28
四、小結 29
第六節、研究問題與假設 30
第三章、研究方法 32
第一節、研究對象與程序 32
第二節、研究工具 36
第三節、資料分析 41
第四章、研究結果 43
第一節、人口學變項及治療前臨床特徵 43
第二節、人口學變項、治療前臨床特徵與療效指標之相關 45
第三節、主要研究發現 47
研究問題一：比較CBT-I組與CBT-I+BF組之療效 47
一、失眠嚴重度改善程度 47
二、失眠嚴重度的臨床改善程度 49
三、睡前激發狀態改善程度 50
四、睡眠自我效能改善程度 52
五、次要變項改善程度 53
六、其他分析：CBT-I組與CBT-I+BF組之治療依從性程度差異 56
七、結果整理 58
研究問題二：探討治療機制中的心理與行為因子之關聯性 58
一、治療依從性各成分之相關 58
二、治療依從性與失眠嚴重度改變量之相關 60
三、睡眠自我效能改變量與失眠嚴重度改變量之相關 61
四、睡眠自我效能改變量與治療依從性之相關 62
五、結果整理 63
第五章、討論 64
第一節、研究摘述 64
第二節、研究結果討論 66
第三節、研究限制與建議 73
第四節、結論 73
參考文獻 75
附錄一、失眠嚴重度量表 88
附錄二、睡眠前激發狀態量表 89
附錄三、睡眠自我效能量表 90
附錄四、HRV-BF Protocol 91		zh_TW
dc.format.extent 4479765 bytes-
dc.format.mimetype application/pdf-
dc.source.uri (資料來源) http://thesis.lib.nccu.edu.tw/record/#G0108752021en_US
dc.subject (關鍵詞) 失眠認知行為治療zh_TW
dc.subject (關鍵詞) 心跳變異率生理回饋zh_TW
dc.subject (關鍵詞) 自我效能zh_TW
dc.subject (關鍵詞) 依從性zh_TW
dc.subject (關鍵詞) 隨機分派臨床試驗zh_TW
dc.subject (關鍵詞) Cognitive behavioral therapy for insomniaen_US
dc.subject (關鍵詞) Heart rate variability biofeedbacken_US
dc.subject (關鍵詞) Self-efficacyen_US
dc.subject (關鍵詞) Adherenceen_US
dc.subject (關鍵詞) Randomized clinical trialen_US
dc.title (題名) 探討CBT-I結合心跳變異率生理回饋介入失眠疾患之療效zh_TW
dc.title (題名) Treatment efficacy of CBT-I combined with HRV Biofeedback for insomnia disorderen_US
dc.type (資料類型) thesisen_US
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