研究背景與目的：失眠為更年期族群常見的健康問題，但更年期並非單指一個階段，而是涵蓋多個階段的歷程，在不同階段的失眠現象也有所不同。過去更年期的相關研究中可以發現儘管生理因素很重要，但認知行為歷程亦為此時期失眠的重要因素，本研究以Harvey失眠認知理論及Lundh和Broman之睡眠干擾與睡眠詮釋歷程整合模型為基礎，上述理論強調，當個體將日間失功能狀況歸因於前一晚的睡眠品質不佳時，容易出現為因應日間功能與睡眠品質不佳的安全行為，而與睡眠有關的安全行為也會讓個體失眠狀況持續，但是就更年期個體而言，日間失功能狀態有可能是因為睡眠狀況不佳，或是更年期的症狀導致。故本研究目的為：探索更年期個體，「症狀歸因」及「失眠嚴重度」之間的關聯與「與睡眠有關的安全行為」的中介效果，也將進一步探索不同更年期階段的「症狀歸因」、「失眠嚴重度」與「與睡眠有關的安全行為」的差異。
研究方法：本研究於線上招募100位45至60歲的女性，排除已經接受子宮或雙側卵巢切除手術、患有重大生理疾患、婦科疾病、其他睡眠、心理疾患者，受試者須填答症狀歸因、與睡眠有關的安全行為和失眠嚴重度的問卷。資料分析的部分本研究以路徑分析驗證「與睡眠有關的安全行為」中介「症狀歸因」和「失眠嚴重度」之間的關係，並且以獨立樣本t檢定及線性迴歸分析檢驗「停經期」及「停經後」在歸因向度、與睡眠有關的安全行為和失眠嚴重度之平均差異及停經階段的調節效果。
研究結果：整體樣本顯示，將日間不適歸因於睡眠品質不佳，可顯著預測更高的主動控制與規劃睡眠的行為頻率，而此類行為亦能顯著預測較高的失眠嚴重度。相對地，將日間不適歸因於更年期則可顯著預測較低的失眠嚴重度。聚焦於更年期起始後首次失眠者，本研究發現其症狀歸因與安全行為間，以及症狀歸因與失眠嚴重度間皆未有顯著效果，而主動控制與規劃睡眠已能顯著預測失眠嚴重度。在更年期階段的比較上，兩組在症狀歸因、安全行為與失眠嚴重度並無顯著差異，亦無法調節症狀歸因及安全行為間的關係。然而，調節分析結果顯示，更年期階段會影響歸因至睡眠與失眠嚴重度，以及歸因至其他因素與失眠嚴重度間的關聯強度。
結論：本研究顯示，更年期失眠並非單一生理現象，而是涉及動態變化的認知與行為歷程。在整體樣本中，將日間不適歸因於睡眠會透過增加與睡眠有關的安全行為而加重失眠，而將不適歸因於更年期則可能對睡眠有保護效果。對於更年期起始後首次失眠者而言，症狀歸因與安全行為之間未存在穩定連結，顯示其可能處在失眠初發階段的「探索期」，個體仍在多種可能解釋之間擺盪。然而，即便在此早期階段，「主動控制與規劃睡眠」已對失眠產生負面影響。此外，更年期階段會改變不同歸因類型與失眠之間的關聯：停經初期失眠較與「歸因到其他因素」有關，而停經後期失眠嚴重度則轉為受到「歸因至睡眠」所影響。此結果表示，更年期歷程可能改變症狀歸因的心理意涵，而非單純改變行為頻率或失眠程度。整體而言，支持更年期失眠為一個隨階段轉變的認知行為歷程，臨床介入應因應不同階段調整焦點。未來研究亦可進一步探討將日間不適歸因於更年期對失眠的保護作用，以深化對更年期失眠心理歷程的理解。

Background and Objectives: Insomnia is a common health concern among menopausal women. However, menopause represents a transitional process comprising multiple stages, during which insomnia manifestations may differ. Previous studies have highlighted the importance of physiological factors, yet cognitive–behavioral processes also play a critical role in menopausal insomnia. Guided by Harvey’s cognitive model of insomnia and the integrated model of sleep interference and sleep interpretation proposed by Lundh and Broman, this study conceptualized that attributing daytime dysfunction to poor sleep quality may increase engagement in sleep-related safety behaviors, which in turn perpetuate insomnia. For menopausal individuals, daytime impairment may arise from either disturbed sleep or menopausal symptoms. Accordingly, this study aimed to examine the association between symptom attribution and insomnia severity, the mediating role of sleep-related safety behaviors, and stage-related differences across menopausal phases.
Methods: A total of 100 women aged 45–60 years were recruited online. Participants with a history of hysterectomy or bilateral oophorectomy, major medical illnesses, gynecological conditions, other sleep disorders, or psychiatric disorders were excluded. Participants completed questionnaires assessing symptom attribution, sleep-related safety behaviors, and insomnia severity. Path analysis was conducted to examine the mediating role of sleep-related safety behaviors in the relationship between symptom attribution and insomnia severity. Independent-samples t tests and linear regression analyses were used to evaluate group differences between women within one year of menopause and those beyond one year menopause, as well as the moderating effects of menopausal stage.
Results: In the overall sample, attributing daytime discomfort to poor sleep quality significantly predicted higher levels of active sleep control and planning behaviors, which in turn significantly predicted greater insomnia severity. In contrast, attributing daytime discomfort to menopause significantly predicted lower insomnia severity. When focusing on women who experienced insomnia for the first time after menopause onset, no significant associations were found between symptom attribution and sleep-related safety behaviors, nor between symptom attribution and insomnia severity; however, active sleep control and planning behaviors already significantly predicted insomnia severity in this subgroup. Comparisons between menopausal stages revealed no significant group differences in symptom attribution, sleep-related safety behaviors, or insomnia severity, and menopausal stage did not moderate the association between symptom attribution and safety behaviors. Nevertheless, moderation analyses indicated that menopausal stage influenced the strength of the associations between attribution to sleep and insomnia severity, as well as between attribution to other factors and insomnia severity.
Conclusion: The present findings suggest that menopausal insomnia is not merely a physiological phenomenon but involves dynamically evolving cognitive–behavioral processes. In the overall sample, attributing daytime discomfort to sleep problems exacerbated insomnia through increased engagement in sleep-related safety behaviors, whereas attributing discomfort to menopause itself appeared to exert a protective effect on sleep. Among women experiencing insomnia for the first time following menopause onset, symptom attribution and safety behaviors had not yet formed stable links, suggesting that this group may be in an early “exploratory phase” of insomnia, during which individuals fluctuate among multiple explanatory frameworks. Nonetheless, even at this early stage, active sleep control and planning behaviors already exerted a negative impact on insomnia severity. Furthermore, menopausal stage altered the pattern of associations between attribution types and insomnia: insomnia during the perimenopausal stage was more strongly associated with attribution to other factors, whereas in the postmenopausal stage, insomnia severity became more closely linked to attribution to sleep. These findings indicate that the menopausal transition may modify the psychological meaning of symptom attribution rather than simply influencing behavior frequency or insomnia severity. Overall, the results support conceptualizing menopausal insomnia as a stage-sensitive cognitive–behavioral process, highlighting the importance of tailoring clinical interventions according to both insomnia trajectory and menopausal phase. Future research should further examine the potential protective role of attributing daytime discomfort to menopause in order to deepen understanding of the psychological mechanisms underlying menopausal insomnia.

書籍：
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