疼痛患者心理障碍评估的项目反应理论分析与应用
摘要
目的：本研究以疼痛患者为研究对象，揭示传统测验理论、单维项目反应理论与多维项目反应理论评估其心理障碍的异同，探讨项目反应理论在临床心理评估中应用的可能性，分析影响疼痛患者心理障碍程度的因素，为构建疼痛管理系统，指导临床实践提供依据。
方法：本研究通过多中心合作，抽取北京、西安、重庆、兰州等地10家医疗机构就诊的具有疼痛症状的患者进行问卷调查。采用医院焦虑抑郁量表（HAD）、患病行为问卷（IBQ）评估患者的心理障碍，应用视觉模拟评分法（VAS）、疼痛强度简易描述量表（VRS）和简化的麦-吉疼痛问卷（SF-MPQ）评估患者的疼痛程度，并对患者的性别、居住环境、所患疾病种类等一般因素进行了调查。应用因素分析等方法探讨了HAD、IBQ的结构，应用内部一致性系数评估了信度，进而利用单维IRT模型（GRM和2PL）和多维IRT模型（Bi-factor模型）对其条目和测验的信息量等进行了分析，并对不同的分析方法进行了对比。同时，也初步评估了三种疼痛程度测量工具的实用性。在此基础上，我们进一步应用相关分析及多元方差分析，探讨了疼痛程度及其他一般因素对于患者心理障碍程度的影响，为临床诊疗过程提供参考。
结果：
1. HAD和IBQ各维度的单维性都不太理想，对比CTT、单维IRT和Bi-factor模型的分析结果，我们发现Bi-factor模型更适合这两个量表的结构和条目特征，心理测量学指标也更理想；
2.应用Bi-factor模型进行分析，患者心理症状之间的关系更为清晰，而且症状的独特特点也得以体现；
3.对于患者疼痛程度的评估VAS量表应用性更好，而SF-MPQ则在患者疼痛性质等方面可以提供更全面的信息；
4.与男性疼痛患者相比，女性疼痛患者情绪的抑制状态更为明显；
5.与居住在城市的疼痛患者相比，居住在乡镇或县城的疼痛患者情绪的主动状态更为明显，而且不恰当的患病行为更为明显；
6.在疼痛患者当中，居住在城市的女性癌症患者和居住在乡镇或县城的女性急性疼痛患者心理障碍程度更为严重，诊疗过程中需要耐心沟通。
结论：IRT可以应用于临床心理症状的评估；多维特征明显的临床量表采用多维模型分析效果更好；疼痛患者的心理障碍程度与疼痛程度密切相关；性别、居住环境和疾病种类在一定程度上影响患者的心理障碍程度。但由于时间和精力有限，本研究仅对疼痛管理综合系统进行了初步构建，对其它临床心理评估的适用性还需进一步的论证。
Purpose In order to provide practical evidence for the benefits of usingItem response theory (IRT) to analyze clinical psychological measures, ClassicalTesting Theory (CTT), unidimensional IRT and multidimensional IRT modelswere used to analyze pain related psychological factors, and the differencesbetween these methods were compared. Additionally, the influences of painseverity and other demographic factors to severity of psychological disorder forpatients with pain were analyzed systematically. All this work was conducted toprovide primary reference for comprising of pain management system, and toprovide guidance for clinical practice.
Methods Ten medical departments were enrolled in this study, locating inBeijing, Xi’an, Chongqing, and Lanzhou cities. Questionnaires were deliveredto outpatients with pain symptoms. Hospital Anxiety and Depression Scale(HAD) and Illness Behavior Questionnaire (IBQ) were used to measure patients’ psychological disorders. Visual analogue scale (VAS), verbal rating scale (VRS)and Short-form of McGill pain questionnaire (SF-MPQ) were used to evaluatethe severity of pain in patients. Also other information of patients wasdocumented, including sex, living in the city or in the country, and classificationof their illnesses. Data was analyzed using the combination of different methods,including factor analysis, coefficients of internal consistency, graded responsemodel (GRM), two-parametric logistic model (2PL), bi-factor model and so on.Different criteria were also used to compare the different methods, includingconstruct validity, consistency, item and test information etc. At the same time,3methods of evaluating the severity of pain were also compared. Based on theseresults, correlation analysis and multivariate analysis of variance wereconducted to assess the influences of pain severity and other demographicfactors having on severity of psychological disorders.
Results We got the following results in this study.
1. The unidimensionality of subscales of HAD and IBQ were not so well.Among the3methods, bi-factor analysis was more appropriate for theconstructs of these two scales and items’ contents. And psychological criteria ofbi-factor analysis were better.
2. Bi-factor analysis made the correlations between different psychologicalsymptoms clearer, and specific characteristics were more obvious.
3. VAS was better when evaluating the severity of pain. And SF-MPQcould provide more detailed information of the characteristics of pain.
4. Compared with male pain patients, females were more passive (specificcharacteristics of depression).
5. Compared with pain patients living in the cities, patients living in thecountry were more active (specific characteristics of anxiety), and had more obvious inappropriate illness behaviors.
6. Among the pain patients, female cancer patients living in the cities andfemale patients with acute pain living in the country had more severepsychological disorders. And doctors should treat them more patiently.
Conclusion In this study we could know that IRT could be applied in theanalysis of clinical psychological evaluations. And multidimensional modelscould get better results for scales with multidimensional characteristics.Obviously, psychological disorders of pain patients were correlated significantlywith their pain severity. Besides, sex, living in the city or the country, andclassification of illnesses could also exert influences on their psychologicalfactors. As a primary exploration for constructing a comprehensive evaluatingsystem of pain, this study could provide some suggestions for clinical practice.However, limited in the time and resources, we still have many shortcomingsneeding to be improved.
方法：本研究通过多中心合作，抽取北京、西安、重庆、兰州等地10家医疗机构就诊的具有疼痛症状的患者进行问卷调查。采用医院焦虑抑郁量表（HAD）、患病行为问卷（IBQ）评估患者的心理障碍，应用视觉模拟评分法（VAS）、疼痛强度简易描述量表（VRS）和简化的麦-吉疼痛问卷（SF-MPQ）评估患者的疼痛程度，并对患者的性别、居住环境、所患疾病种类等一般因素进行了调查。应用因素分析等方法探讨了HAD、IBQ的结构，应用内部一致性系数评估了信度，进而利用单维IRT模型（GRM和2PL）和多维IRT模型（Bi-factor模型）对其条目和测验的信息量等进行了分析，并对不同的分析方法进行了对比。同时，也初步评估了三种疼痛程度测量工具的实用性。在此基础上，我们进一步应用相关分析及多元方差分析，探讨了疼痛程度及其他一般因素对于患者心理障碍程度的影响，为临床诊疗过程提供参考。
结果：
1. HAD和IBQ各维度的单维性都不太理想，对比CTT、单维IRT和Bi-factor模型的分析结果，我们发现Bi-factor模型更适合这两个量表的结构和条目特征，心理测量学指标也更理想；
2.应用Bi-factor模型进行分析，患者心理症状之间的关系更为清晰，而且症状的独特特点也得以体现；
3.对于患者疼痛程度的评估VAS量表应用性更好，而SF-MPQ则在患者疼痛性质等方面可以提供更全面的信息；
4.与男性疼痛患者相比，女性疼痛患者情绪的抑制状态更为明显；
5.与居住在城市的疼痛患者相比，居住在乡镇或县城的疼痛患者情绪的主动状态更为明显，而且不恰当的患病行为更为明显；
6.在疼痛患者当中，居住在城市的女性癌症患者和居住在乡镇或县城的女性急性疼痛患者心理障碍程度更为严重，诊疗过程中需要耐心沟通。
结论：IRT可以应用于临床心理症状的评估；多维特征明显的临床量表采用多维模型分析效果更好；疼痛患者的心理障碍程度与疼痛程度密切相关；性别、居住环境和疾病种类在一定程度上影响患者的心理障碍程度。但由于时间和精力有限，本研究仅对疼痛管理综合系统进行了初步构建，对其它临床心理评估的适用性还需进一步的论证。
Purpose In order to provide practical evidence for the benefits of usingItem response theory (IRT) to analyze clinical psychological measures, ClassicalTesting Theory (CTT), unidimensional IRT and multidimensional IRT modelswere used to analyze pain related psychological factors, and the differencesbetween these methods were compared. Additionally, the influences of painseverity and other demographic factors to severity of psychological disorder forpatients with pain were analyzed systematically. All this work was conducted toprovide primary reference for comprising of pain management system, and toprovide guidance for clinical practice.
Methods Ten medical departments were enrolled in this study, locating inBeijing, Xi’an, Chongqing, and Lanzhou cities. Questionnaires were deliveredto outpatients with pain symptoms. Hospital Anxiety and Depression Scale(HAD) and Illness Behavior Questionnaire (IBQ) were used to measure patients’ psychological disorders. Visual analogue scale (VAS), verbal rating scale (VRS)and Short-form of McGill pain questionnaire (SF-MPQ) were used to evaluatethe severity of pain in patients. Also other information of patients wasdocumented, including sex, living in the city or in the country, and classificationof their illnesses. Data was analyzed using the combination of different methods,including factor analysis, coefficients of internal consistency, graded responsemodel (GRM), two-parametric logistic model (2PL), bi-factor model and so on.Different criteria were also used to compare the different methods, includingconstruct validity, consistency, item and test information etc. At the same time,3methods of evaluating the severity of pain were also compared. Based on theseresults, correlation analysis and multivariate analysis of variance wereconducted to assess the influences of pain severity and other demographicfactors having on severity of psychological disorders.
Results We got the following results in this study.
1. The unidimensionality of subscales of HAD and IBQ were not so well.Among the3methods, bi-factor analysis was more appropriate for theconstructs of these two scales and items’ contents. And psychological criteria ofbi-factor analysis were better.
2. Bi-factor analysis made the correlations between different psychologicalsymptoms clearer, and specific characteristics were more obvious.
3. VAS was better when evaluating the severity of pain. And SF-MPQcould provide more detailed information of the characteristics of pain.
4. Compared with male pain patients, females were more passive (specificcharacteristics of depression).
5. Compared with pain patients living in the cities, patients living in thecountry were more active (specific characteristics of anxiety), and had more obvious inappropriate illness behaviors.
6. Among the pain patients, female cancer patients living in the cities andfemale patients with acute pain living in the country had more severepsychological disorders. And doctors should treat them more patiently.
Conclusion In this study we could know that IRT could be applied in theanalysis of clinical psychological evaluations. And multidimensional modelscould get better results for scales with multidimensional characteristics.Obviously, psychological disorders of pain patients were correlated significantlywith their pain severity. Besides, sex, living in the city or the country, andclassification of illnesses could also exert influences on their psychologicalfactors. As a primary exploration for constructing a comprehensive evaluatingsystem of pain, this study could provide some suggestions for clinical practice.However, limited in the time and resources, we still have many shortcomingsneeding to be improved.
引文
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