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    題名: 初診斷乳癌患者創傷後成長與心理適應的關係之長期追蹤研究－從創傷後成長異質性變化軌跡的觀點探討
    A Longitudinal Study of the Relationship between Posttraumatic Growth and Psychological Adjustment in Women Newly Diagnosed with Breast Cancer－Are There Distinct PTG Trajectories ?
    作者: 王韋婷
    Wang, Wei Ting
    貢獻者: 許文耀
    Hsu, Wen Yau
    王韋婷
    Wang, Wei Ting
    關鍵詞: 創傷後成長
    心理適應
    因應策略
    認知投入
    自覺脆弱性
    變化軌跡
    乳癌
    posttraumatic growth
    psychological adjustment
    coping strategies
    cognitive engagement
    perceived vulnerability
    trajectory
    breast cancer
    日期: 2013
    上傳時間: 2014-08-12 14:05:37 (UTC+8)
    摘要: 本研究試圖釐清乳癌患者創傷後成長（PTG）與心理適應之間的關係，由於過去實徵資料顯示PTG與心理適應間的關係相當不一致，之所以如此，可能的原因是PTG具有異質性的變化軌跡，本研究從這樣觀點，認為探討乳癌患者的PTG與心理適應的關係必須先探討PTG異質性軌跡的可能性，因此衍生出本研究的三個主要研究問題：一、乳癌患者的PTG變化軌跡是否具有異質性？二、若第一項研究問題成立，則探討PTG不同軌跡組別在影響PTG的相關變項上是否具有差異，以瞭解不同PTG軌跡組別患者的特性，三、PTG不同軌跡組別與心理適應的關係為何？
    本研究採縱貫研究設計，參與者為359位初診斷乳癌患者，於手術後隔日（診斷後平均41天）、術後3個月、術後6個月、術後一年進行PTG、影響PTG的相關變項與心理適應（焦慮、憂鬱、正向情緒）的測量，其中，311人完成三點以上的測量，本研究利用群體軌跡模式（TRAJ）的分析方法，探討這311位乳癌患者的PTG變化軌跡數目。結果顯示可將PTG變化軌跡分出四組，分別為PTG下降組、PTG上升組、PTG中度維持組、PTG高度維持組（分別占全體樣本13.3%、11.5%、36.7%、38.4%）。
    本研究進而探討PTG四個軌跡組別在各種影響PTG的相關變項上的差異，靜態相關變項（背景及醫療變項、自尊與社會期許性、主觀癌症衝擊度）以卡方差異檢定及變異數分析來探討組別差異，動態相關變項（自覺脆弱性、因應方式、認知投入方式）則以『潛在成長模型（LGM）』來探討動態變項之初始值與改變程度在PTG四組上的差異。結果發現不同PTG組別在年紀、教育程度、自尊、自覺脆弱性、因應策略與認知投入方式上具有顯著差異，PTG高度維持組的患者年紀較輕、教育程度較高、自覺脆弱性較高，而其適應性因應策略的採用及認知投入（苦惱自責與深思反省）亦較多；反之，PTG下降組的患者年紀較大、教育程度較低、自覺脆弱性亦較低且隨時間減少，而其適應性策略的採用及認知投入都較低，並且隨時間降低。PTG中度維持組的年齡較輕、教育程度居中（高中畢業者較多），PTG上升組年齡較大、教育程度較低，這兩組的自尊都比PTG高度維持組低，在適應性因應與深思反省上，這兩組的分數都介在PTG高度維持組與PTG下降組之間，但PTG中度維持組比起PTG上升組採用較多的適應性因應，而PTG上升組則是隨著時間自覺脆弱性逐漸增加。上述結果支持PTG軌跡組別的區分是具有效度的。
    由於本研究假定探討PTG與心理沮喪間的關係需考慮樣本的異質性，不論是PTG或心理沮喪均可能存在異質性，因此本研究亦利用TRAJ分析心理沮喪是否具有不同的變化軌跡。研究結果得到乳癌患者的焦慮程度具有四種變化軌跡：低焦慮組、次焦慮組、中高焦慮組、高焦慮組（分別占全體樣本31.6%、41.9%、17.2%、9.2%）；憂鬱程度亦可區分為四組變化軌跡：低憂鬱組、中憂鬱組、憂鬱下降組、高憂鬱組（分別占全體樣本48.2%、26.0%、11.1%、14.7%）。接著利用雙軌跡模型探討PTG與心理沮喪之變化軌跡的關聯性，結果發現PTG下降組的患者焦慮程度最低，且PTG與焦慮的關聯性有類似曲線的關係；PTG與憂鬱雙軌跡模式則出現負向關聯的型態，PTG高度維持組與低憂鬱組關聯性最強。故，本研究假定探討PTG與心理沮喪間的關係需考慮PTG與心理適應軌跡的異質性，獲得初步的支持。
    本研究以LGM探討PTG四組在焦慮、憂鬱、正向情緒（PA）上的變化差異，結果與雙軌跡模式的發現是一致的：PTG下降組的焦慮程度最低，PTG高度維持組的憂鬱程度最低。而PA則與PTG軌跡的PTG程度有正相關。
    最後，本研究追蹤174位乳癌患者於術後兩年的心理適應狀況，以探討PTG組別的預測效度。在控制相關背景變項後，PTG高度維持組於術後兩年具有最佳的心理適應狀況。PTG中度維持組與PTG上升組則具有較高的焦慮與憂鬱程度。PTG下降組具有較低的焦慮程度，但憂鬱分數介於中間。另外，PTG高度維持組的PA顯著的比其他三組來得高。
    總結而言，研究結果支持本研究的假設—乳癌患者的PTG具有不同變化軌跡，且背景變項、自尊、因應方式、認知投入、自覺脆弱性較能夠區分不同PTG軌跡組別之乳癌患者，而PTG不同軌跡組別的心理適應也具有差異。本研究認為乳癌患者面對疾病的方式有很大差異，PTG下降組的患者具有『不投入』的特性，因此PTG很低，也較少心理沮喪；排除PTG下降組的患者之後，PTG與心理沮喪之相關支持『PTG具有正向適應的特性』之假設，因為PTG與焦慮、憂鬱都具有負相關，與PA具有正相關。PTG高度維持組則是心理投入最多的一組乳癌患者，且手術兩年後，心理適應狀況最佳，面對癌症，他們表現出奮鬥迎戰的精神。本研究亦發現，適度的焦慮是必要的，但憂鬱會阻礙PTG的產生。本研究於討論中，針對研究結果在理論與臨床應用上的意涵進行探討，並提出對未來研究的建議。
    Objectives: Empirical studies of the relationship between posttraumatic growth (PTG) and psychological adjustment have revealed a fairly inconclusive picture. After reviewing theories and empirical studies regarding the relationship between PTG and psychological adjustment, the current study argues that the inconsistent findings are likely due to the heterogeneity of the PTG experience over time. In this regard, individuals with different PTG trajectories vary in the level of adjustment and have distinct psychological characteristics. The first aim of this study is to identify different trajectories of PTG. The second aim of this study focuses on the validity of the categorization of PTG trajectory groups. That is, whether different trajectory groups of PTG are different in demographic and medical variables, cancer impact, self-esteem, social desirability (static PTG correlates), and coping styles, cognitive engagement, and perceived vulnerability (time-varying PTG correlates). The third aim of this study is to test whether PTG trajectory groups predicts psychological adjustment.
    Methods: Participants were Taiwanese women newly diagnosed with breast cancer. Measures of PTG, PTG correlates and adjustment outcomes, including anxiety, depression, and positive affect (PA) , were assessed at 1 day and 3, 6, and 12 months after surgery. Of the 359 women who consented to participate at baseline, 311 completed the measures at least three times and were included in the analyses. A group-based trajectory model (TRAJ) was used to identify subpopulations of individuals who shared homogenous PTG change patterns. Moreover, “dummy variables as covariate Latent Growth Curve Models (LGM)” were applied to test time-varying correlates. Then, we explored the relationship between PTG and psychological adjustment by dual trajectory model and LGM. Last, we determined whether the PTG trajectory groups predicted psychological adjustment at 24 months after surgery.
    Results: The patients were categorized into the following four groups, which showed very different patterns of PTG change over the first year after breast cancer surgery: stable high (38.4%), middle stable (36.7%), low increasing (11.5%), and sharp decreasing (13.3%). These four groups were different at static and time-varying correlates. Especially, the higher the PTG level, the more adaptive coping strategies, cognitive engagement, and perceived vulnerability. Of noted, these groups had difference on neither medical variables nor cancer severity.
    We also found four distinct trajectories for either anxiety or depression. They were low anxiety, mild anxiety, moderate anxiety, and high anxiety groups and low depression, mild depression, depression decreasing, and high depression groups. Dual trajectory models showed that the sharp decreasing PTG group had the lowest anxiety level, while the high stable PTG group had the lowest depression level. Curvilinear relationship was found between PTG and anxiety, whereas negative correlation was found between PTG and depression. Differences in the level of adjustment at 24 months and the patterns of the correlations across time were found among these latent subgroups. The high stable PTG group had the least psychological distress and the highest PA. The sharp decreasing PTG group had a rather low level of anxiety but medium level of depression. The middle stable and low increasing groups showed the highest level of distress and a rather low level of PA.
    Conclusions: This study was the first longitudinal examination of PTG trajectories and their different levels of psychological adjustment. The findings support our argument that identifying distinct PTG trajectories can better understand the nature of the relationship between PTG and psychological adjustment. Further theoretical and practical implications for each PTG trajectories are discussed.
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