陳雙藝，仇劍崟

上海交通大學(xué)醫(yī)學(xué)院附屬精神衛(wèi)生中心心理咨詢部，上海 200030

中國(guó)精神衛(wèi)生調(diào)查顯示，國(guó)內(nèi)精神障礙（除癡呆癥外）的終身患病率約為16.5 7%，常見精神障礙包括焦慮癥、心境障礙、物質(zhì)使用障礙、沖動(dòng)控制障礙及精神分裂癥等［1］。在一定程度上，上述疾病均與壓力事件的發(fā)生相關(guān)，如創(chuàng)傷性事件、重大挑戰(zhàn)、生活轉(zhuǎn)變、軀體疾病等壓力事件均會(huì)誘發(fā)個(gè)體的焦慮、抑郁甚至幻覺、妄想等精神癥狀；在應(yīng)對(duì)壓力事件時(shí)，部分高心理韌性的個(gè)體可以保持或迅速恢復(fù)良好的心理健康狀況，而低心理韌性的個(gè)體則不然［2］。相較于以往以精神障礙癥狀為導(dǎo)向的心理健康指標(biāo)，心理韌性這一健康指標(biāo)則可在群體中篩選易感人群，將癥狀導(dǎo)向的研究模式轉(zhuǎn)變?yōu)橐越】禐閷?dǎo)向的研究模式，實(shí)現(xiàn)精準(zhǔn)化心理健康干預(yù)［2］。

1 心理韌性的定義

“Resilience”常被翻譯為“韌性”“彈性”“復(fù)原力”等，強(qiáng)調(diào)個(gè)體的復(fù)原能力。在目前的研究中，尚未對(duì)心理韌性的界定形成統(tǒng)一標(biāo)準(zhǔn)，但多數(shù)定義均圍繞“逆境”和“積極適應(yīng)”2個(gè)核心展開［3］。

較為公認(rèn)的心理韌性的定義主要基于以下3個(gè)角度考慮：個(gè)體特質(zhì)或能力、逆境積極結(jié)果、動(dòng)態(tài)適應(yīng)過程。如Connor等［4］認(rèn)為心理韌性是個(gè)體應(yīng)對(duì)逆境（如壓力、創(chuàng)傷等）時(shí)仍能保持適應(yīng)性行為的能力。Masten［5］則將心理韌性視為一種發(fā)展框架或一個(gè)適應(yīng)系統(tǒng)，強(qiáng)調(diào)個(gè)體經(jīng)歷壓力事件后所產(chǎn)生的積極結(jié)果。Kalisch等［2］在總結(jié)前人研究的基礎(chǔ)上，發(fā)現(xiàn)個(gè)體在成功應(yīng)對(duì)壓力事件的過程中會(huì)出現(xiàn)4個(gè)變化，即人生觀層面的改變、新優(yōu)勢(shì)或能力的出現(xiàn)、對(duì)未來壓力源的部分免疫以及表觀遺傳學(xué)或基因表達(dá)模式的改變；且該研究認(rèn)為，心理韌性并非一種穩(wěn)定的個(gè)體特質(zhì)，也不是特定的基因型或大腦結(jié)構(gòu)，其應(yīng)是適應(yīng)特定壓力生活環(huán)境的動(dòng)態(tài)過程，強(qiáng)調(diào)個(gè)體主動(dòng)、動(dòng)態(tài)適應(yīng)，不僅取決于個(gè)體特質(zhì)、基因型或大腦結(jié)構(gòu)，還取決于壓力源的性質(zhì)和其他復(fù)雜因素。

2 心理韌性的評(píng)估

隨著心理韌性研究的不斷深入，其評(píng)估工具和方法也在臨床上得到了同步發(fā)展。目前，量表評(píng)估是心理韌性最為常用的評(píng)估方法。研究者多側(cè)重于心理韌性的保護(hù)性因素或內(nèi)在結(jié)構(gòu)編制心理韌性量表，具有良好的信效度。Wagnild等［6］編制的心理韌性量表（Resilience Scale，RS）將心理韌性劃分為能力、自我與生活接納共3個(gè)維度。Connor等［4］基于能力、特質(zhì)角度編制的心理韌性量表（Connor-Davidson Resilience Scale，CD-RISC）是臨床上應(yīng)用最為廣泛的評(píng)估量表，包括個(gè)體能力、忍受、變化接受度、控制、精神影響5個(gè)維度，共25個(gè)條目。該量表在社區(qū)、保健門診、普通精神科門診等的就診人群中均表現(xiàn)出良好的信效度。Yu等［7］根據(jù)本土化結(jié)果將CD-RISC的5個(gè)維度修改為3個(gè)，即堅(jiān)韌、自強(qiáng)和樂觀，并修訂了該量表的中文版。CD-RISC英文版和中文版均采用5級(jí)評(píng)分，得分越高表示個(gè)體心理韌性水平越高。且橫斷面研究［4］發(fā)現(xiàn)，CD-RISC得分較高的心理韌性個(gè)體的心理健康問題較少。

除針對(duì)心理韌性的量表測(cè)量外，基于結(jié)果角度的定義，研究者們發(fā)現(xiàn)可通過壓力事件發(fā)生后個(gè)體的心理癥狀反映其心理韌性水平。如McAndrew等［8］以心理健康綜合評(píng)分（the Mental health composite score，MCS）作為經(jīng)歷戰(zhàn)爭(zhēng)部署后的軍隊(duì)士兵心理韌性的指標(biāo)。針對(duì)創(chuàng)傷后患者，常以創(chuàng)傷后個(gè)體的相關(guān)癥狀或適應(yīng)性功能的缺乏作為其心理韌性的衡量指標(biāo)，如創(chuàng)傷后應(yīng)激障礙癥狀量 表（Post-Traumatic Stress Disorder Symptom Scale，PSS）［9］。同時(shí)，有研究采用抑郁自評(píng)量表（Self-Rating Depression Scale，SDS）和焦慮自評(píng)量表（Self-Rating Anxiety Scale，SAS）來評(píng)估個(gè)體在應(yīng)對(duì)壓力過程中的心理韌性水平的動(dòng)態(tài)變化［10］。此外，還有部分研究通過腦成像［11］、頭發(fā)皮質(zhì)醇［12］、基因組［13］等神經(jīng)生物學(xué)指標(biāo)來反映個(gè)體心理韌性水平。而研究者們有針對(duì)性地采用量表評(píng)分與神經(jīng)生物學(xué)指標(biāo)相結(jié)合的方式全面評(píng)估個(gè)體的心理韌性，或?qū)樾睦眄g性的動(dòng)態(tài)變化提供更多維度的指標(biāo)。

3 心理韌性與精神障礙癥狀的關(guān)系

研究［14-15］顯示，心理韌性可以概念化為與壓力源暴露相關(guān)的心理健康指標(biāo)，可緩沖因壓力源暴露后的個(gè)體的不良心理健康狀態(tài)。如，CD-RISC得分對(duì)積極情緒具有強(qiáng)預(yù)測(cè)性，提示心理韌性在以積極情緒中斷為特征的精神障礙（如抑郁癥）中具有重要作用［16］。橫斷面研究［17-20］發(fā)現(xiàn)，心理韌性與個(gè)體的抑郁焦慮程度、創(chuàng)傷后癥狀水平均呈顯著負(fù)相關(guān)；同時(shí)，其可在創(chuàng)傷和個(gè)體心理健康狀況之間發(fā)揮中介作用［21］。心理韌性與創(chuàng)傷后應(yīng)激障礙（post-traumatic stress disorder，PTSD）、焦慮癥、抑郁癥等精神障礙的發(fā)生也密切相關(guān)［22-23］。Xi等［23］對(duì)九寨溝地震發(fā)生后3個(gè)月的重災(zāi)區(qū)民眾進(jìn)行調(diào)查發(fā)現(xiàn)，心理韌性對(duì)民眾的PTSD有直接影響，同時(shí)還可通過焦慮、抑郁癥狀對(duì)PTSD產(chǎn)生間接影響。Liu等［24］針對(duì)新冠疫情背景下的美國(guó)898例18～30歲成人群體的橫斷面調(diào)查發(fā)現(xiàn)，心理韌性與低水平的焦慮、抑郁癥狀相關(guān)。

研究［25］發(fā)現(xiàn)心理韌性還會(huì)削弱焦慮癥狀與賭博成癮之間的聯(lián)系，并認(rèn)為成癮類精神障礙的心理治療可針對(duì)性地改善患者的心理韌性［26］。另有研究［27-28］考察了心理韌性與網(wǎng)絡(luò)游戲障礙（internet gaming disorder，IGD）間的關(guān)系，結(jié)果顯示IGD組相較于健康對(duì)照組的心理韌性更低，究其原因可能與IGD患者的抑郁癥狀有關(guān)；同時(shí)，上述研究還發(fā)現(xiàn)心理韌性可通過增加個(gè)體的積極情緒來減輕IGD癥狀。由此可見，心理韌性與個(gè)體應(yīng)對(duì)壓力后是否表現(xiàn)出精神障礙癥狀密切相關(guān)。

4 心理韌性的干預(yù)

研究［29］提示，心理治療可以改善個(gè)體的心理韌性，減輕精神障礙癥狀，從而提高其心理健康水平。常規(guī)心理治療如認(rèn)知行為療法（cognitive-behavioral therapy，CBT）能夠幫助個(gè)體進(jìn)行認(rèn)知重塑，對(duì)壓力事件做出更積極的解釋，從而有效減少創(chuàng)傷后的負(fù)面癥狀［30］。馮彩英等［31］開展的隨機(jī)對(duì)照研究發(fā)現(xiàn)，與干預(yù)組相比，骨折患兒術(shù)后24 h施行干預(yù)+CBT可顯著增強(qiáng)其心理韌性及康復(fù)依從性，有效緩解其負(fù)性情緒。非隨機(jī)對(duì)照研究［32］發(fā)現(xiàn)，為期6周的CBT能夠增強(qiáng)共病PTSD和藥物使用障礙的退伍軍人的心理韌性，且心理韌性的改善與PTSD癥狀的減少顯著相關(guān)。同時(shí)，有研究發(fā)現(xiàn)正念（mindfulness）對(duì)心理韌性的改善也具有一定的積極效果：對(duì)有犯罪問題的青少年進(jìn)行10 d正念干預(yù)及生活技能訓(xùn)練，結(jié)果發(fā)現(xiàn)正念與青少年心理韌性及情緒行為問題的改善顯著相關(guān)［33］；且通過隨機(jī)對(duì)照試驗(yàn)（randomized controlled trial，RCT）發(fā)現(xiàn)，僅4 d的短程正念練習(xí)也能夠提高個(gè)體心理韌性得分［34］。

Zamirinejad等［35］報(bào)道，對(duì)個(gè)體心理韌性的干預(yù)能夠改善抑郁癥患者的抑郁癥狀。Christopher等［36］基于正念的 韌 性 干 預(yù) （mindfulness-based resilience training，MBRT）結(jié)合了正念與韌性的改善；Penn韌性項(xiàng)目（Penn resilience program，PRP）是基于認(rèn)知行為理論開發(fā)的一項(xiàng)針對(duì)學(xué)生的韌性訓(xùn)練計(jì)劃，注重提高個(gè)體的認(rèn)知行為技能［37］；壓力管理、心身增彈訓(xùn)練（Stress management and resiliency training，SMART）是一個(gè)針對(duì)性提升個(gè)體心理韌性的12周項(xiàng)目［38］。經(jīng)過RCT驗(yàn)證發(fā)現(xiàn)，上述針對(duì)性干預(yù)能夠顯著降低干預(yù)組的壓力水平，改善個(gè)體的心理韌性。一項(xiàng)針對(duì)重癥監(jiān)護(hù)病房護(hù)士的心理韌性訓(xùn)練研究［39］顯示，干預(yù)后護(hù)士的CD-RISC得分顯著增加，職業(yè)壓力水平顯著下降；但該研究未設(shè)置對(duì)照組。對(duì)現(xiàn)役軍人韌性訓(xùn)練的有效性進(jìn)行驗(yàn)證，發(fā)現(xiàn)韌性訓(xùn)練可幫助軍人改善焦慮、抑郁癥狀或睡眠問題［40］，也有助于減少創(chuàng)傷對(duì)軍人心理健康的有害影響［41］。因此，韌性訓(xùn)練能夠有效幫助個(gè)體改善癥狀，且不同韌性項(xiàng)目的側(cè)重亦有所不同。研究者們可進(jìn)一步開發(fā)更具針對(duì)性的心理韌性干預(yù)方式，改善個(gè)體的心理韌性，以考察心理韌性與個(gè)體癥狀之間的關(guān)系。

同時(shí)，針對(duì)心理韌性的干預(yù)研究的設(shè)置并不統(tǒng)一，且干預(yù)形式也存在較大差異［42］。如：研究中的評(píng)估時(shí)間點(diǎn)應(yīng)遵循療效研究的設(shè)置，至少需包括干預(yù)前測(cè)、干預(yù)后測(cè)及干預(yù)后隨訪；干預(yù)期間內(nèi)可開展多次評(píng)估，以更精確地研究個(gè)體心理韌性在干預(yù)中的變化軌跡；亦可開展長(zhǎng)期隨訪評(píng)估，以確定個(gè)體在后續(xù)面對(duì)壓力源時(shí)的心理健康狀況及心理韌性變化。

除研究設(shè)置外，目前針對(duì)精神障礙患者的干預(yù)研究鮮少以心理韌性的改善為指標(biāo)，而多采用精神障礙癥狀進(jìn)行衡量［30］；且以心理韌性為指標(biāo)的干預(yù)研究對(duì)象多集中于兒童青少年、高風(fēng)險(xiǎn)職業(yè)群體（如軍人、醫(yī)療工作者等）或重大疾病患者。研究［30，43］發(fā)現(xiàn)，心理韌性干預(yù)在已遭受創(chuàng)傷的群體中的效果較低。因此對(duì)高風(fēng)險(xiǎn)職業(yè)群體的心理韌性干預(yù)還需要在壓力源暴露之前進(jìn)行，從而改善此類群體的心理韌性、增強(qiáng)其應(yīng)對(duì)壓力的能力。

5 總結(jié)

由于心理韌性易受到多種因素的影響，其概念具復(fù)雜性和模糊性，具體的保護(hù)性因素和風(fēng)險(xiǎn)性因素也需進(jìn)一步探討［44］。目前，心理韌性評(píng)估指標(biāo)尚不足以體現(xiàn)其概念，研究者應(yīng)有意識(shí)地將其視為一種動(dòng)態(tài)過程，而非單一的結(jié)果或穩(wěn)定的特質(zhì)。

心理韌性的可改變性也驗(yàn)證了其基于過程的動(dòng)態(tài)性定義的合理性。將心理韌性作為心理干預(yù)的療效指標(biāo)是可行的，但相關(guān)干預(yù)研究也存在較多問題，如研究設(shè)計(jì)無法體現(xiàn)其有效性、療效研究設(shè)置不科學(xué)、研究對(duì)象集中等。

總之，心理韌性的研究正處于轉(zhuǎn)型期，基于過程的動(dòng)態(tài)性心理韌性定義將為研究者提供新的視角與理解，同時(shí)也將提出新的評(píng)估與研究要求［45］。除此之外，臨床心理治療師也應(yīng)在治療過程中注重對(duì)來訪者的心理韌性的培養(yǎng)；后續(xù)相關(guān)研究也可有針對(duì)性地開發(fā)改善個(gè)體心理韌性的干預(yù)方法，將心理韌性作為心理干預(yù)療效或心理健康狀況指標(biāo)，以健康為導(dǎo)向，促進(jìn)個(gè)體心理健康發(fā)展。

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