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肖雪
陳侃
大健康學院
應用心理學博士學位課程
博士
2023
意象體現療法對急性冠脈綜合征合併抑鬱患者的身心干預
Psychosomatic intervention of Embodied Imagination therapy for patients with acute coronary syndrome complicated with depression
急性冠脈綜合征 ; 意象體現治療 ; 抑鬱 ; 生活品質 ; 心率變異性 ; 心血管事件
acute coronary syndrome ; Embodied Imagination therapy ; depression ; quality of life ; heart rate variability ; cardiovascular event
公開日期:2/1/2026
本研究目的在於探索短程意象體現技術在急性冠脈綜合征合併抑鬱患者治療中的臨床應用,評估其對患者情緒、軀體伴隨症狀及生活品質的改善效果,旨在探索心身疾病患者有效的心理幹預模式。
本研究通過隨機對照實驗和個案分析方法進行兩方面的研究:研究一通過隨機對照實驗設計,連續入選 2020 年 9月至 2022 年 3 月在北京兩家三甲醫院心內科門診就診的急性冠脈綜合征合併輕中度抑鬱患者,隨機分為意象體現組(30例)和藥物組(30 例)。意象體現組在常規心內科藥物治療的基礎上,給予個體意象體現治療8周,每次60分鐘,每週一次。藥物組在常規心內科治療的基礎上, 給予抗抑鬱藥舍曲林口服治療。分別於治療前,治療4周、8週末後,以及24週末隨訪時,採用漢密爾頓抑鬱量表(HAMD-17)、漢密爾頓焦慮量表(HAMA)、西雅圖心絞痛量表(SAQ)、醫學應對問卷(MCMQ)進行評估,檢測心率變異性(HRV),同時記錄不良反應及不良心血管事件。統計分析比較組間及組內的差異,驗證意象體現治療模式對急性冠脈綜合征患者的心身療效,檢驗療效是否不劣於抗抑鬱藥舍曲林,同時分析其優勢治療維度。研究二採用個案分析的方法進行研究,搜集過程資料,深入探討意象體現治療模式的改變機制。
研究結果:
1.意象體現治療能夠改善急性冠脈綜合征合併抑鬱患者的抑鬱、焦慮,失眠以及伴隨的軀體不適症狀。研究顯示在治療早期(治療4週末)抗抑鬱藥物治療起效更快,藥物短期療效優於意象體現治療。但在治療結束(治療8週末),及半年後隨訪時,兩組患者在抑鬱、焦慮及伴隨症狀的改善上無明顯差異。
2.統計分析西雅圖心絞痛量表五個維度的評分,在幹預 4周、8周及24周隨訪時兩組患者的軀體活動受限程度、心絞痛穩定狀態、心絞痛的發作頻率、治療的滿意程度及疾病認知五個維度的評分均有所升高,進一步比較發現,意象體現組在疾病認知維度,在幹預4周、8周及24周隨訪時評分均高於藥物組,有統計學差異。意象體現治療和抗抑鬱藥物治療都能在緩解情緒的同時,改善急性冠脈綜合征患者的機能狀態和生活品質。且意象體現組患者在疾病認知維度的效果要顯著優於藥物組。
3.意象體現治療能夠讓患者減少消極應對疾病,更多的採取面對疾病的應對方式,有利於疾病的預後。經過8周治療,意象體現組“回避”應對方式比藥物組顯著減少,“面對”應對方式比藥物組顯著增加。這種差異在半年後隨訪時仍然存在。
4.與基線比較,患者經意象體現治療4周後,心率變異性無顯著性變化,但8週末及半年隨訪時SDNN、SDANN、RMSSD、PNN50值顯著升高,LF值顯著減低,與藥物組變化趨勢基本一致,表明兩種幹預方式對急性冠脈綜合征患者心率變異性的影響相似。
5.以8週末HAMD-17量表評分進行非劣效性檢驗,非劣效性界值為3.2,差異有統計學意義,意象體現治療對急性冠脈綜合征合併抑鬱患者抗抑鬱療效不劣於抗抑鬱藥。
6.兩組再次血運重建、非致死心肌梗死、心力衰竭、總體心血管事件組間比較均無統計學差異。
研究結論:
1.意象體現治療對於急性冠脈綜合征合併抑鬱患者有確切幹預效果,且療效不劣於常用抗抑鬱藥物舍曲林。均能在緩解患者情緒問題的同時,改善急性冠脈綜合征患者預後,降低不良心血管事件的發生,提高患者機能狀態及生活品質。意象體現治療能夠對治病的深層心理因素起到幹預效果,減少患者“回避”應對,同時可能通過影響患者下丘腦—垂體—腎上腺素軸(HPA)自律性的喚醒,進而影響心臟交感和副交感神經的張力,從而發揮身心共愈的治療效果,從而影響冠脈綜合征患者的遠期預後。
2. 個案分析表明意象體現治療的治癒路徑及改變機制:首先讓個案確認身體的不適感,辨別症狀的心臟和心理來源。選擇患者覺得與軀體症狀有關的重要夢境進行工作,通過視角轉換技術,夢者擴展了慣常的執著的“我”,治療中從非慣性的視角獲得更多的體驗。另外隨著意象的湧現,過往經驗被喚醒,回憶起壓抑在身體的記憶,通過多重身體感受的對比和整合形成新的記憶,對創傷身體記憶進行化解,實現心身療愈的效果。
Objective:
This study examines how short-course Embodied Imagination therapy is used to treat acute coronary syndrome patients paired with depression in a clinical setting, as well as to determine whether it improves patients' mood, their somatic symptoms and their quality of life, with the aim of exploring effective psychological intervention models for those suffering from psychosomatic conditions.
Methods:
1. There were a total of 30 patients in Study 1 who, between September 2020 and March 2022, attended outpatient clinics of cardiology departments at two hospitals in Beijing with acute coronary syndrome and mild to moderate depression. They were randomly assigned to either the Embodied Imagination treatment group (30 cases) or the medication treatment group (30 cases) based on the results of a randomized, controlled, non-inferiority experimental design. Embodied imagination was given to patients in the Embodied Imagination group, along with conventional cardiology medication, for eight weeks, twice a week, in addition to conventional cardiology treatment. In the drug group, the antidepressant sertraline was given orally in addition to the conventional cardiology treatment. The Hamilton Depression Scale (HAMD-17), Hamilton Anxiety Inventory (HAMA), Seattle Angina Scale (SAQ), and Medical Coping Questionnaire (MCMQ) were used for assessment before treatment, after 4 and 8 weeks of treatment, and at the follow-up visit at the end of 24 weeks, respectively, to detect heart rate variability (HRV), and to record adverse effects and cardiovascular events. Statistical analysis was used to compare the differences between groups and within groups, to verify the psychosomatic efficacy of Imagery Embodiment therapy in patients with acute coronary syndrome, to test whether the efficacy was not inferior to the antidepressant sertraline, and to analyze its superior treatment dimension.
2. Using a case study approach to collect process data and to investigate in depth the mechanism of change in the Embodied Imagination therapy model.
Results:
1. Embodied Imagination treatment improved depression, anxiety, insomnia, and concomitant somatic symptoms in patients with acute coronary syndrome combined with depression. The study showed that antidepressant medication had a faster onset of action early in treatment (at the end of 4 weeks of treatment) and that the short-term efficacy of the medication was better than that of Embodied Imagination treatment. However, at the end of treatment (8 weekends of treatment) and at the six-month follow-up, there was no significant difference in the improvement of depression, anxiety, and concomitant symptoms between the two groups.
2. Statistical analysis of the scores of the five dimensions of the Seattle Angina Scale showed that the scores of the five dimensions of limitation of physical activity, stable state of angina, frequency of angina attacks, satisfaction with treatment and disease perception increased in both groups at 4 weeks, 8 weeks and 24 weeks follow-up of the intervention, and further comparison revealed that the Embodied Imagination group had higher scores in the disease perception dimension, at The scores at 4 weeks, 8 weeks and 24 weeks follow-up of the intervention were statistically higher in the Embodied Imagination group than in the drug group. Both Embodied Imagination treatment and antidepressant treatment improved functional status and quality of life in patients with acute coronary syndrome while relieving mood. Patients in the Embodied Imagination group had significantly better outcomes than the medication group in the disease perception dimension.
3. Embodied Imagination treatment can help patients to cope with the disease less negatively and more confrontation with the disease, which is beneficial to the prognosis of the disease. After 8 weeks of treatment, the Embodied Imagination group showed a significant decrease in "avoidance" coping and a significant increase in "confrontation" coping compared to the medication group. This difference persisted at the six-month follow-up.
4.Compared with baseline, there was no significant change on heart rate variability(HRV) after 4 weeks of Embodied Imagination treatment . However, the values of SDNN, SDANN, RMSSD, PNN50 were significantly higher at the end of 8 weeks and at the six-month follow-up, and the LF value decreased significantly , which were generally consistent with the trend of the drug group, indicating that both interventions had similar effects on heart rate variability in patients with acute coronary syndrome. The effects of both interventions on HRV in patients with acute coronary syndrome were similar.
5.The non-inferiority test with the HAMD-17 scale score at the end of 8 weeks showed a non-inferiority threshold of 3.2, which was statistically significant, and the antidepressant efficacy of Embodied Imagination was not inferior to that of antidepressants in patients with acute coronary syndrome combined with depression.
6. There was no statistically significant difference between the two groups in terms of re-vascularization, non-fatal myocardial infarction, heart failure, and overall cardiovascular events.
Conclusion:
Embodied Imagination treatment has a definite intervention effect on patients with acute coronary syndrome combined with depression, and the efficacy is not inferior to antidepressant medication. Embodied Imagination treatment can improve the prognosis of patients with acute coronary syndrome, reduce the incidence of cardiovascular events, and improve the functional status and quality of life of patients while alleviating their emotional problems. Embodied Imagination treatment can interfere with the deep psychological factors of the treatment, reduce the patient's "avoidance" response, and may affect the long-term prognosis of patients with coronary syndromes by influencing the arousal of the autonomic hypothalamic-pituitary-adrenergic axis (HPA), which in turn affects the sympathetic and parasympathetic tone of the heart.
Through a detailed analysis of the short course of Embodied Imagination, we explore the healing path and alters mechanisms of psychotherapy for psychosomatic disorders. In the treatment, the case is first asked to identify the physical discomfort and to identify the cardiac and psychological sources of the symptoms. Through the perspective-shifting technique, the dreamer expands the usual obsessive "I" and has more experience from a non-dominant perspective in the treatment. In addition, with the emergence of imagery, past experiences are awakened, memories repressed in the body are recalled, and new memories are formed by comparing and integrating multiple bodily sensations, and traumatic bodily memories are dissolved. The body, as a mind-body network, becomes a holding place for spiritual materials, constantly adapting to its surroundings, making adjustments, and achieving mind-body healing effects.
2023
中文
192
致 謝 I
摘 要 III
Abstract VII
圖目錄 XVI
表目錄 XVII
第一章 緒 論 1
1.1 研究背景及意義 1
1.2 研究目的 7
第二章 “雙心”理論的研究與綜述 9
2.1 “雙心”概念的起源 10
2.2 中國傳統文化視角下的“雙心”關係 11
2.2.1 儒家的心 13
2.2.2 道家的心 15
2.2.3 佛家的心 16
2.3 傳統中醫視角下的“雙心”理論 17
2.4 精神動力學視角下的“雙心”理論 20
第三章 ACS患者的心理社會因素 26
3.1 ACS的概念及診斷 26
3.2 ACS患者的心理應激 27
3.3 急性冠脈綜合征與抑鬱 28
3.3.1 ACS與抑鬱的相關性 28
3.3.2 ACS患者抑鬱的識別、篩查與評估 30
3.4 ACS與D型人格 33
第四章 ACS共病抑鬱的機制及治療 36
4.1 ACS共病抑鬱的機制 36
4.1.1 ACS共病抑鬱的生物學機制 36
4.1.2 ACS中醫的病因病機 39
4.2 ACS共病抑鬱的治療 40
4.2.1 西醫治療 40
4.2.2 心理治療 41
第五章 夢工作理論與應用的實證研究綜述 45
5.1經典精神分析取向的釋夢觀點 45
5.1.1 佛洛伊德的釋夢觀點 45
5.1.2 榮格的釋夢觀點 46
5.1.3 阿德勒的釋夢觀點 49
5.2 現代心理學的夢工作方法 51
5.2.1 Johnson的釋夢方法 51
5.2.2 Ullman的夢工作方法 52
5.2.3 Hill的夢工作方法 52
5.3 夢在心理治療中應用的相關研究 53
5.3.1 夢的意義及在心理治療中的作用 53
5.3.2 夢的內容與心理疾病和心身疾病的關係 55
5.3.3 夢的工作方法和療效的實證研究 57
第六章 意象體現技術對ACS合併抑鬱治療的隨機對照研究 59
6.1 意象體現技術對ACS合併抑鬱患者治療理論及框架 59
6.1.1 意象體現技術的簡介及操作方法 59
6.1.2 短程意象體現技術對雙心疾病患者的治療路徑 67
6.1.3 意象體現技術對心身疾病的治療原理 69
6.2 研究方法 73
6.2.1 研究物件 74
6.2.2 評估方法 76
6.2.3 實施方案 78
6.2.4 結果評估 80
6.2.5 統計分析方法 82
6.2.6 品質控制 83
6.2.7 擬採取的具體步驟 83
6.2.8 技術路線圖 84
6.3 研究結果 85
6.3.1 基線臨床資料比較 85
6.3.2 療效分析 87
6.3.2.1 HAMD-17評分的比較 88
6.3.2.2 HAMA評分的比較 95
6.3.2.3 PSQI評分的比較 100
6.3.2.4 SAQ評分的比較 102
6.3.3 應對方式變化的比較 111
6.3.4 心率變異性指標的比較 115
6.3.5 臨床有效率的比較 117
6.3.6 非劣效性檢驗 117
6.3.7 安全性分析 118
6.3.8 心血管事件比較 119
6.3.9 小結 119
6.4 討論 123
6.4.1 意象體現治療對ACS合併抑鬱患者抑鬱及伴隨症狀的影響 124
6.4.2 意象體現治療對ACS合併抑鬱患者生活品質的影響 125
6.4.3 意象體現治療對ACS合併抑鬱患者應對方式的影響 126
6.4.4 意象體現治療對ACS合併抑鬱患者心率變異的影響 127
第七章 意象體現技術對ACS合併抑鬱治療的個案研究 131
7.1 個案基本情況 131
7.2 評估、分析與診斷 135
7.3 目標與計畫 136
7.3.1 諮詢目標 136
7.3.2 諮詢計畫 137
7.4 諮詢過程 137
7.4.1 初始訪談、身體感覺的探索與症狀澄清 138
7.4.2 知己知彼,有的放矢 139
7.4.3 初始夢的工作 141
7.4.4 噩夢的工作 144
7.4.5 夢境轉變,水利萬物,獲得力量 149
7.5 討論 153
第八章 研究結論、不足與展望 155
8.1 研究結論 155
8.2 研究不足 156
8.3 研究展望 156
參考文獻 158
作者簡歷 174
附 錄 176
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