# 臨床健康心理學

Biopsychosocial model

# 壓力
- 發生了什麼？
- 發生頻率、強度、持續時間
- 身體狀況
- 人際關係
- 因應狀況

## 什麼是壓力？
人無法處理環境的要求，感覺緊張與不舒服。

三種衝突分類：
- Approach/approach：兩種選擇都很吸引人。
- Avoidance/avoidance：兩種選擇都不想要。
- Approach/avoidance：只有一種選擇，希望能得到它的好處而不要壞處。

## 壓力定義
- 環境
- 人對壓力的反應
- 人與環境的關係

### 環境
- Life Event：
Social Readjustment Rating Scale(SRRS)將壓力源做評分與排序，可作參考但不是絕對如此

- Daily Hassles：
人們日常生活中的不愉快或可能有害的事件。
Hassles 比起 Life Event 跟健康更有關聯

### 人對壓力的反應
General Adaptation Syndrome:
- Alarm Reaction
- Stage Resistance
- Stage of Exhaustion

### 人與環境的關係
個人所擁有的資源不足以滿足環境要求

## 壓力評估
- Primary appraisal
- irrelevant
- good
- stressful，壓力有三種含義：
- harm-loss：已經發生的傷害e.g.天災過後
- threat：預期會發生傷害
- challenge：挑戰與表現的機會

- Secondary appraisal 人對因應壓力的資源評估
- 我可以做到
- 我做不到
- 我需要找人幫忙
- 我需要更努力點

## 壓力因應 Coping
身體花了一些努力來弭平自身資源與環境需求的差異（壓力來源）

- 你用什麼方式面對它？
- 怎麼處理？
- 有什麼成效？
- 接下來呢？

壓力因應兩面向：
- 解決壓力來源 Problem-focused coping
- 相信自己可以做到
- 相信情況可以改變
- Problem-focused therapy
- 調整情緒反應
- 行為：尋求親友支持、轉移注意力
- 認知：改變想法
- redefine重新定義：情況可能更糟、有人比我更糟


- Well behavior：健康狀況下去做的預防行為
- Symptom-based behavior：出現症狀後尋求幫助
- Sick-role behavior：進入病人角色後的行為，可以免除部份義務與責任，有文化差異

## 理論模型
### The health belief model
人會不會採取預防行動，取決於他對結果的兩個評估：
- 知覺到的威脅：
- seriousness 嚴重性
- susceptibility 易受感染性：自己發展成這結果的機率
- 影響行動的cues
- 知覺到的好處與阻礙：
- 四項當中，知覺阻礙在預防情境下最有效果，好處是在臨床場域最有效果

支持
不支持

### The theory of planned behavior
「Intention」才會導致 Behavior。

Intention 由三個因子組成：
- **Attitude 態度**
- behavior beliefs
- evaluations of behavioral outcomes

- **Subjective norm 社會規範**
- normative beliefs 對社會規範的看法
- motivation to comply

- **Perceived control**
- control beliefs：自我效能，自我控制感
- perceived power

支持：
- 三者與intention有相關。
- 減重成果與Perceived control有關聯。
- self-efficacy、attitude比起憂鬱，更能預測自傷行為。

### The stages of change model
1. Precontemplation 沒有要改變的意識
2. Contemplation 想要改變了
3. Preparation
4. Action
5. Maintenance
- counterconditioning 反制約
- helping relationships 讓朋友幫忙監督
- reinforcement 酬賞
- stimulus control 避免刺激物


### 理論反思
- 理論內容、變項定義與特徵、扮演角色為何？
- 證據？
- 對不同的行為都適用嗎？
- 如何應用來改變？
- 如何搭配環境與其他因素的設計？e.g.房屋設計、政策設計

# 菸酒、營養、飲食與運動

## Substance abuse
- **Addiction**:
is a condition produced by repeated consumption of a natural or synthetic psychoactive substance, in which the person has became physically and psychologically dependent on the substance (Baker et al., 2004)

- **Craving**:
is a motivational state that involves a **strong desire** for using s substance.

- **Substance abuse**:
failing, to fulfill important obligations, putting oneself or others at repeated risk for physical injury, having substance-related legal difficulties

### Addiction & Dependence
- **Tolerance**:
is the process by which the body increasingly adapt to a substance and **requires larger does of it to achieve the same effect.**

- **Withdrawal**:
refers to **unpleasant physical and psychological symptoms** people experience when they discontinue or markedly reduce using a substance on when they have become dependent.

- **Dependence:**
includes physical and psychological dependence.

- physical dependence
exists when the body has adjusted to a substance and incorporated it into the normal functioning to the body’s tissues.

- psychological dependence
is a state in which individuals feel compelled to use a substance for the effect it produces, without necessarily being physical dependent on it.

### Processes leading to dependence
- Reinforcement
- positive reinforcement: added pleasant or wants after the behavior occurs.

- negative reinforcement: reduced or removed an aversive circumstance.

- Substance-related cues:
when people use substances, they associate with that activity the specific internal and environmental stimuli that are regularly present, which are called cues. Classical conditioning.

- learning the cues enables the body to anticipate and compensate for the substance’s effects.

- **incentive-sensitization theory**: the neurotransmitter, dopamine

## Smoking tobacco
### Becoming a regular smoker:

- Individuals who smoke their fourth cigarette are very likely to become regular smokers.

- Becoming a habitual smoker usually takes a few years, and the faster the habit develops, the more likely the person will smoke heavily and have trouble quitting (Dierker et al., 2008)
- smoking by family and friends promotes through reduces the belief that smoking is harm for their health,

- teenagers usually smoke in the presence of other people,

- feeling negative emotions increases people’s smoking (McCaffery et al., 2008)

## Alcohol use and abuse

- Binge drinking:
is consuming five or more drinks on a single occasion at least once in a 30-day period.

- Heavy use drinking:
involves binge drinking five or more times in a month.

- Problem drinkers:
drink heavily on a regular basis and suffer social and occupational impairments from it. The lifetime prevalence rate is 17%

- Alcoholics:
the individual who abuse alcohol are physically dependent on or addicted to it

### Who drinks and how much

- Female on average experience more intoxication than male

- Countries: integrate alcohol into daily life, Italy and France; restrict alcohol use, USA

- Most problem drinkers are married, living with their families, and employed, and many are women.

### Why people use and abuse alcohol
•The chief reasons for starting to drink involve social and cultural factors.

•Teenager: feelings of depression, believe their friends drink a lot, have low school grades, have parents who drink and provide little monitoring or rules against drinking

•Social modeling, social pressure, and subjective norm

•Positive reinforcement and negative reinforcement (only with the first few drinks)

•(1) heavy drinkers are more likely to perceive fewer negative consequences for drinking.

•(2)heavy drinkers tend to experience high levels of stress, and live in environments that encourage drinking.

•(3) heavy drinkers may form particularly strong substance-related cues.

•(4) people who drink moderation are more likely to use alcohol control strategies.

•(5) biological factors

## Reducing substance use and abuse
### 藥物
•Bupropion hydrochloride

•Varenicline

•Disulfiram

•Naltrexone

•Methadone

•

## Nutrition and eating

## Exercise

# 醫療服務


# 心理腫瘤學(Psycho-Oncology)

治療方法：藥物治療、化學治療、放射線治療、標靶治療、免疫治療




不斷重新評估、調整，而不是執著於一開始的目標


團隊合作模式：
- 第一級：知道彼此的專業，彼此明確的分工
- 第二級：知道彼此的專業，而且彼此討論、合作
- 第三級：團隊成員成一體，對病人而言是統一的窗口，成員可以承擔彼此的部分功能（例如：心理師可以提供醫療資訊、醫師可以提供心理支持）

---
范聖育老師的想法：

$$
\text{diagnosis}\rightarrow \text{treatment} \rightarrow \text{relapse}\rightarrow \text{end of life}\rightarrow \text{death}
$$

疾病有身體症狀與心理成分，要與醫師討論他的藥物與放射治療是否會造成這些身體症狀。也要注意腦傷的部分，如何從患者的行為回推腦傷的部分。

在醫院工作的時候，病人歸屬於一個科下面，沒辦法同時跨腫瘤科與精神科。

三方溝通：
1. 患者的症狀：認知、情緒、行為分析與介入，對死亡的焦慮、心願及其他在意的事項。
2. 家屬：家屬的知識、負擔、社會支持、經濟。bereavement喪親之痛
3. 醫療團隊：醫療決定、成員間支持

影響健康行為的因素：
- 個人：害怕後果、懶惰、人際關係、信仰、威脅、益處、自我效能感、因應策略（問題導向、情緒導向）。
- 環境：環境中的cue（霧霾、廁所的衛教宣導）、名人宣傳、學校教育。

控制環境中的線索、尋求朋友幫助

# 癌症病人與家屬照護

資料來源
- 病人：
- 家屬：盡量讓家屬與自己站在同一陣線
- 病歷：雖然看過病歷，但要不要告訴病人自己決定。
- 醫護人員：

衡鑑測驗
- 標準化問卷：
- 心情：
- 疼痛指數（0~10分）
- 困擾溫度計（0~10分）
- 憂鬱問卷：BSRS-5
- 需求：
- Cancer Patients Needs Questionaire(CPNQ)
- NEST：四個向度（需求、存在、症狀、治療），細項有財務、得到照顧、心理壓力、親近......
- 生活品質：一般性+疾病特定
- EORTC QLQ-C30（歐盟）
- FACT-G
- SF-36
- WHOQOL（世界衛生組織）
- 全人衡鑑的架構：生理、心理、社會、靈性、實務、照顧計畫與未來
- 癌症病人心理衡鑑架構：個人向度、生活背景向度、疾病向度

- 臨床晤談：
內心要有架構，除了測驗與問卷外，應針對內心的架構從行為與對話中搜集資料。
- 壓力模型：
- 生命活力與資源對生活事件的因應目標：
- CBT：事件 -> 認知 -> 行為