焦虑对青少年抑郁症患者非自杀性自伤行为的近端作用及改良认知行为疗法的干预效果：一项生态瞬时评估研究

Proximal effect of anxiety on non-suicidal self-injury behaviors in adolescent patients with depression and the intervention efficacy of modified cognitive behavioral therapy： an ecological momentary assessment study

中文关键词:  青少年  抑郁症  生态瞬时评估  认知行为治疗  非自杀性自伤行为  负性情绪

英文关键词:Adolescents  Depression  Ecological momentary assessment  Cognitive behavioral therapy  Non-suicidal self-injury behaviors  Negative emotions

中文摘要:

      背景 近年来，青少年抑郁症的发病率不断上升，而非自杀性自伤（NSSI）行为在该人群中也日益凸显，可能增加其自杀风险，构成了严峻的公共卫生问题。焦虑、抑郁等负性情绪与NSSI行为密切相关，既往研究多依赖回顾性报告，难以动态捕捉情绪波动与NSSI行为的时序关联，且认知行为疗法（CBT）在干预NSSI行为时往往缺乏针对近端诱因的靶向设计。目的 验证焦虑是青少年抑郁症患者NSSI行为的近端触发因子，并评估整合生态瞬时评估（EMA）数据的改良CBT对降低其焦虑水平及自伤欲望的效果。方法 采用前瞻性队列研究设计，选取2024年1月—12月在九江市第五人民医院治疗、符合《精神障碍诊断与统计手册（第5版）》（DSM-5）抑郁症诊断标准且存在NSSI行为史的青少年患者132例。采用智能手机EMA程序，对受试者进行连续14天的自然情境情绪监测。监测时间为每日10∶00—22∶00，每2小时随机推送一次评估。评定工具包括焦虑自评量表（SAS）和正性负性情绪量表（PANAS）中的负性情绪分量表，并实时记录NSSI行为及其发生前后的情绪状态。采用重复测量方差分析，比较NSSI行为发生前后各量表评分。对完成EMA数据采集的83例受试者实施为期12周、每周1次的改良CBT。于干预前后，采用SAS评定焦虑水平，采用渥太华自我伤害调查表（OSI）评定自伤欲望。结果 EMA数据显示，NSSI行为发生前1~2小时，SAS评分高于基线期［（56.19±11.06）分vs.（52.83±10.25）分，P<0.01］。SAS评分与NSSI行为评分呈正相关（r=0.460，P<0.01，95% CI：0.310~0.580）。接受改良CBT干预后，青少年抑郁症患者SAS评分［（52.30±8.10）分vs.（48.70±7.30）分，t（82）=4.820，P<0.01，Cohen’s d=0.420］和OSI自伤冲动分量表评分［（12.80±2.70）分vs.（9.60±2.50）分，t（82）=5.170，P<0.01，Cohen’s d=0.510］均低于干预前，差异均有统计学意义。结论 焦虑可能是青少年抑郁症患者NSSI行为的近端触发因素，整合EMA数据的改良CBT可能有助于降低其焦虑水平和自伤欲望。

英文摘要:

      Background In recent years， the prevalence of depression among adolescents has risen steadily， alongside an increasing prominence of non-suicidal self-injury （NSSI） behaviors in this population， which may elevate suicide risk and constitute a serious public health problem. Negative emotions such as anxiety and depression are closely related to NSSI behaviors. Previous studies have predominantly relied on retrospective reports， limiting the ability to dynamically capture temporal relationships between emotional fluctuations and NSSI behaviors. Moreover， cognitive behavioral therapy （CBT） often lacks targeted design to address proximal triggers in interventions for NSSI behaviors.Objective To verify that anxiety as a proximal trigger factor for NSSI behaviors in adolescent patients with depression， and to evaluate the efficacy of modified CBT integrated with ecological momentary assessment （EMA） data in alleviating their anxiety and self-injury urges.Methods A prospective cohort study design was adopted. A total of 132 adolescent patients with a history of NSSI behaviors who were treated at Jiujiang Fifth People's Hospital from January to December 2024 and met the diagnostic criteria for depression in the Diagnosed and Statistical Manual of Mental Disorders， fifth edition （DSM-5）. A smartphone-based EMA application to conduct natural situation emotions on participants for 14 consecutive days. The monitoring period spanned from 10∶00 to 22∶00 daily， with randomized assessments pushed every 2 hours. The assessment tools included the Self-rating Anxiety Scale （SAS） and the negative affect subscale of the Positive and Negative Affect Schedule （PANAS）， with real-time recording of NSSI behaviors and emotional states before and after their occurrence. Repeated measures analysis of variance was used to compare the dynamic changes in the scores of each scale before and after the episodes of NSSI behaviors. A modified CBT was administered to 83 participants who completed EMA data collection， with sessions conducted once weekly for 12 weeks. Anxiety levels were accessed using the SAS， and the self-injury urges was evaluated using the Ottawa Self-injury Inventory （OSI） before and after the intervention.Results EMA data revealed that SAS scores were significantly higher during the 1-2 hours before NSSI episodes compared to baseline periods ［（56.19±11.06）vs.（52.83±10.25），P<0.01］. SAS scores were positively correlated with the NSSI behavioral scores （r=0.460，P<0.01，95% CI：0.310-0.580）. After receiving modified CBT intervention， adolescent patients with depression demonstrated statistically significant decreases in both SAS scores ［（52.30±8.10） vs.（48.70±7.30），t（82）=4.820，P<0.01，Cohen's d=0.420］ and the OSI self-injury impulse subcale scores ［（12.80±2.70） vs.（9.60±2.50），t（82）=5.170，P<0.01，Cohen's d=0.510］ compared to their pre-intervention levels.Conclusion Anxiety may serve as a proximal trigger for NSSI behaviors in adolescent patients with depression. Modified CBT integrating EMA data could potentially alleviate their anxiety level and self-injury urges. ［Funded by Science and Technology Plan Project of Jiangxi Provincial Health Commission （number， SKJP220227629）］