Introduction
The term “morale,” as defined by Merriam-Webster, reflects an individual’s psychological well-being, rooted in a sense of purpose and future confidence.1 Conversely, “demoralization,” according to the Encarta World English Dictionary, signifies the deterioration of courage, confidence, or hope, whether in an individual or a group.2 Demoralization, therefore, represents a loss of a critical psychological essence, distinct from the diagnostic construct of depression.
The distinction between demoralization and depression holds significant importance, particularly in palliative care settings. Many researchers have voiced concerns that the distress experienced by individuals facing serious illnesses often falls outside the conventional mood and anxiety disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM).3–5 In the context of palliative care, where patients grapple with life-limiting conditions, understanding and accurately classifying these unique forms of distress becomes paramount. Demoralization is increasingly recognized as a clinically relevant entity in this population. This article aims to explore the concept, clinical features, assessment methods, prevalence, and potential treatments for demoralization, specifically within the framework of palliative care. Identifying and addressing demoralization is crucial to enhancing the quality of life and psychological well-being of patients in palliative care.
The Concept of Demoralization in Palliative Care
The concept of demoralization was initially introduced by Jerome Frank, who characterized affected individuals as feeling powerless, isolated, despairing, alienated, rejected, and possessing low self-esteem.7 Frank’s initial conceptualization focused on the psychotherapy of psychiatric patients, emphasizing the therapist’s role in combating demoralization across therapeutic approaches.7 However, in the context of palliative care, demoralization takes on a specific meaning related to the experience of serious illness.
Within palliative care, demoralization extends beyond the general dictionary definition. It encompasses the fundamental psychological elements of disempowerment – the inability to maintain previous functional levels – and a profound sense of futility – the belief that the medical condition and its consequences will never improve. For patients in palliative care, this sense of futility can be particularly poignant as they face progressive illnesses and diminishing prospects for recovery.
Given the profound physical and psychosocial challenges inherent in severe medical conditions, especially those requiring palliative care, a degree of demoralization may be considered a normative or expected reaction.8 This suggests that demoralization exists on a spectrum, ranging from normal responses to severe, clinically significant impairment. In palliative care, distinguishing between normative distress and clinically significant demoralization is vital for appropriate intervention.
Clinical Features of Demoralization in Palliative Care Patients
Numerous researchers have provided clinical descriptions outlining the psychological characteristics of demoralization in medically ill patients.9–14 These descriptions are particularly relevant to understanding the emotional and existential distress experienced by patients in palliative care. Table 1 summarizes some of these proposed psychological features. While dysphoria is a central affective component of demoralization, feelings of helplessness and hopelessness are consistently highlighted across various descriptions. In palliative care, these feelings can be intensified by the progressive nature of illness and the awareness of mortality.
Table 1.
Proposed psychological features of demoralization
| Author | Year of Publication | Description |
|---|---|---|
| D’Arcy9 | 1982 | anxiety, sadness, helplessness, hopelessness, lack of self-esteem |
| de Figueiredo10 | 1993 | distress, subjective incompetence |
| Kissane et al11 | 2001 | hopelessness, loss of meaning, existential distress |
| Clarke et al12 | 2003 | anxiety, apprehension, inability to cope, loss of confidence, helplessness, hopelessness |
| Griffith et al13 | 2005 | despair, helplessness, sense of isolation |
| Clarke et al14 | 2006 | inability to cope, helplessness, hopelessness, diminished personal esteem |
It is important to note that many of the descriptors in Table 1, such as sadness and hopelessness, may overlap with symptoms of depression. However, the literature emphasizes key distinctions between demoralization and mood disorders, crucial for accurate diagnosis and intervention in palliative care. De Figueiredo emphasizes that demoralization is characterized by feelings of subjective incompetence and helplessness, whereas depression is distinguished by anhedonia, or a diminished capacity to experience pleasure.10 Clarke and Kissane further clarify that hedonic capacity remains relatively intact in demoralized individuals, unlike those with depression.3 This distinction is critical in palliative care, where patients may still find moments of joy and connection despite their illness, even while experiencing profound demoralization.
Empirical research supports these distinctions. For instance, Clarke et al.12 found that demoralization was associated with avoidance coping mechanisms, while anhedonic depression was linked to reduced social engagement and fewer close relationships. These findings reinforce the understanding that demoralization, while sharing dysphoria with depression, is a distinct psychological entity, particularly relevant in the context of serious medical illness and palliative care. Recognizing these nuances is crucial for healthcare professionals in palliative care to provide targeted and effective support.
Assessment of Demoralization in Palliative Care Settings
Accurate assessment of demoralization is essential in palliative care to differentiate it from other forms of psychological distress, such as depression or anxiety, and to guide appropriate interventions. Several tools and approaches can be utilized for this purpose.
Diagnostic Criteria for Psychosomatic Research (DCPR). Recognizing the limitations of DSM classifications in capturing the psychological distress experienced by individuals with somatic illnesses, an international consortium developed the Diagnostic Criteria for Psychosomatic Research (DCPR) in 1995.15 The DCPR is a structured interview comprising 58 yes/no questions, designed to identify 12 distinct psychosomatic syndromes (Table 2). This instrument demonstrates strong interrater reliability, with kappa values for individual syndromes ranging from 0.69 to 0.97; specifically, demoralization showed a kappa value of 0.90.16 Research by Grassi et al.17 indicates a low overlap between DCPR and DSM diagnoses. For example, 58% of patients diagnosed via DCPR did not meet criteria for a DSM disorder, suggesting the DCPR effectively captures clinical phenomena outside the scope of traditional DSM categories. This is particularly relevant in palliative care, where distress may not always fit neatly into DSM diagnoses.
Table 2.
Psychosomatic Syndromes Identified by the Diagnostic Criteria for Psychosomatic Research (DCPR)15
| Alexithymia (i.e., a deficiency in understanding, processing, or describing emotions) |
|---|
| Type A behavior |
| Irritable mood |
| Demoralization |
| Disease phobia |
| Thanatophobia (i.e., an abnormal and excessive fear of death) |
| Health anxiety |
| Illness denial |
| Functional somatic symptoms secondary to a psychiatric disorder |
| Persistent somatization |
| Conversion symptoms |
| Anniversary reactions |
According to the DCPR, the diagnosis of demoralization requires meeting the following criteria: 1) a feeling state characterized by the patient’s awareness of failing to meet personal or others’ expectations or inability to cope with pressing problems, resulting in feelings of helplessness, hopelessness, or giving up; 2) the feeling state is persistent, generalized, and present for at least one month; and 3) the feeling state is closely linked to the manifestation or exacerbation of a medical disorder. These criteria are highly pertinent in palliative care, where patients often face increasing functional limitations and a sense of loss of control due to their illness.
Demoralization Scale of the Restructured Clinical Scales of the MMPI-2. The Minnesota Multiphasic Personality Inventory, version 2 (MMPI-2), includes restructured clinical scales designed to differentiate somatic symptoms from other psychological constructs, including depression.18 The demoralization scale, part of these restructured scales, assesses a respondent’s current sense of well-being, ranging from life satisfaction to dissatisfaction and despair. Studies have shown this scale to be a reliable predictor of rehabilitation outcomes.19 While the MMPI-2 is typically administered and interpreted by a psychologist and involves associated costs, it offers a valuable quantitative measure of demoralization. In palliative care, this tool can provide a more objective assessment of demoralization severity.
While both the DCPR and MMPI-2 Demoralization Scale are valuable assessment tools, their structured format and administration requirements may limit their routine use in busy clinical palliative care settings. Therefore, clinicians in palliative care should also rely on clinical observation and patient interviews to identify demoralization. Paying attention to patients’ expressions of helplessness, hopelessness, loss of meaning, and inability to cope can provide crucial insights into their demoralization levels.
Prevalence of Demoralization in Medical and Palliative Care Populations
Several studies, utilizing the DCPR, have investigated the prevalence of demoralization across various clinical populations. Studies have reported prevalence rates of demoralization in endocrine patients at 34 percent (50/146); 39 percent (85/219) in inpatients referred to consultation/liaison services; 30.4 percent (245/807) in consecutive medical outpatients; 28.8 percent (42/146) among cancer patients; and 33 percent (33/100) in medical patients diagnosed with adjustment disorder according to DSM criteria.23 These findings consistently indicate that approximately one-third of medically ill patients experience clinically significant demoralization.
While specific prevalence data for demoralization in palliative care populations using DCPR may be less readily available, it is reasonable to expect similar or potentially higher rates. Patients in palliative care often face more advanced and debilitating illnesses, increased symptom burden, and existential distress related to end-of-life issues, all of which can contribute to demoralization. Further research is needed to specifically quantify the prevalence of demoralization in palliative care settings, but clinicians should be aware that it is likely a common and significant issue in this population. Recognizing this high potential prevalence underscores the importance of routine screening and assessment for demoralization in palliative care.
Treatment and Interventions for Demoralization in Palliative Care
While a comprehensive discussion of demoralization treatment is beyond the scope of this article, several authors offer valuable insights into potential interventions, particularly relevant to palliative care. Griffith et al.13 emphasize the importance of identifying and addressing underlying existential themes contributing to demoralization. In palliative care, these themes may include loss of autonomy, fear of suffering and death, concerns about burdening loved ones, and spiritual or existential crises.
Kissane et al.11 propose a range of therapeutic strategies including ensuring continuity of care, proactive symptom management, exploring patients’ attitudes towards hope and meaning in life, balancing support for grief with fostering hope, facilitating the search for renewed purpose and roles, cognitive restructuring of negative beliefs, spiritual and religious support, promoting social connectedness, and enhancing family functioning. These approaches are highly relevant in palliative care, where a holistic, patient-centered approach is paramount. Active symptom management is particularly crucial in alleviating physical distress that can contribute to demoralization. Exploring meaning and purpose, providing spiritual support, and strengthening social connections can address the existential and emotional dimensions of demoralization in palliative care patients.
Sirri et al.4 highlight the significance of consistent, supportive, and empathetic interactions with healthcare providers, alongside cognitive-behavioral techniques. In palliative care, where trust and communication are central to the patient-provider relationship, empathetic and consistent support from the palliative care team can be profoundly therapeutic in combating demoralization. Cognitive-behavioral techniques can help patients reframe negative thoughts and develop coping strategies to manage their distress and enhance their sense of control within the limitations of their illness.
Furthermore, interventions such as dignity therapy and meaning-centered psychotherapy, specifically developed for palliative care populations, may also be effective in addressing demoralization by fostering a sense of meaning, purpose, and dignity in the face of serious illness and end-of-life concerns. Integrating psychosocial and spiritual care into routine palliative care practice is essential for addressing demoralization effectively.
Conclusions
Demoralization is a prevalent and clinically significant psychological phenomenon among medically ill patients, including those in palliative care, often inadequately addressed by traditional DSM diagnoses. Characterized by dysphoria but distinct from depression, demoralization is rooted in feelings of disempowerment and futility. This syndrome is estimated to affect approximately one-third of medical patients and is likely equally or more prevalent in palliative care settings.
While formal assessment tools like the DCPR and MMPI-2 restructured clinical scales exist, their practical application in busy clinical settings may be limited. Therefore, clinicians in palliative care should be vigilant in recognizing medically related dysphoria and actively assess for underlying demoralization through clinical observation and patient interviews. Identifying demoralization is the first crucial step towards providing appropriate support and interventions.
Addressing demoralization in palliative care requires a multi-faceted approach, integrating symptom management, existential exploration, psychosocial support, and spiritual care. By recognizing demoralization as a distinct and relevant psychiatric diagnosis in palliative care and implementing targeted interventions, healthcare professionals can significantly enhance the psychological well-being and quality of life for patients facing serious illness and end-of-life challenges. Demoralization represents a critical area of concern that bridges the psychiatric and palliative care interface, demanding increased attention and integrated care approaches.
Contributor Information
Randy A. Sansone, Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio.
Lori A. Sansone, Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.
References
[1] Merriam-Webster. Morale. In: Merriam-Webster’s online dictionary [Internet]. Springfield, MA: Merriam-Webster; 2024 [cited 2024 Jun 19]. Available from: https://www.merriam-webster.com/dictionary/morale
[2] Encarta World English Dictionary. Demoralization. In: Encarta World English Dictionary [Internet]. United Kingdom: Bloomsbury Publishing Plc; 2009 [cited 2024 Jun 19].
[3] Clarke DM, Kissane DW. Demoralization: its phenomenology and importance. Aust N Z J Psychiatry. 2002 Dec;36(6):733-42. doi: 10.1080/j.1440-1665.2002.02475.x. PMID: 12485392.
[4] Sirri L, Fava GA, Sonino N. Recognizing and treating demoralization in patients with medical disease. Psychother Psychosom. 2007;76(2):65-76. doi: 10.1159/000097987. PMID: 17325452.
[5] Grassi L, Caruso R, Mitchell AJ. The distress of medical illness: psychopathological or physiological? Psychother Psychosom. 2010;79(1):4-20. doi: 10.1159/000262895. PMID: 19955737.
[6] Clarke DM, McKenzie DP, Koczwara B, Kissane DW, Phillips JL, Milross C. Demoralization syndrome in cancer patients and their carers. Psychooncology. 2014 Dec;23(12):1399-406. doi: 10.1002/pon.3577. Epub 2014 Mar 27. PMID: 24677523.
[7] Frank JD. Persuasion and healing: A comparative study of psychotherapy. Baltimore: Johns Hopkins University Press; 1974.
[8] Chochinov HM, Stone P. Depression in cancer patients: assessment and determinants. Lancet Oncol. 2006 Dec;7(12):1027-37. doi: 10.1016/S1470-2045(06)70942-0. PMID: 17145411.
[9] D’Arcy C. Chronic illness and demoralization. Towards a method of assessment. Can J Psychiatry. 1982 Aug;27(5):375-80. doi: 10.1177/070674378202700508. PMID: 7119142.
[10] de Figueiredo JM. Broadening the concept of minor affective disorder: demoralization and its differential diagnosis. Compr Psychiatry. 1993 May-Jun;34(3):161-71. doi: 10.1016/0010-440X(93)90054-Q. PMID: 8314814.
[11] Kissane DW, Clarke DM, Street AF. Demoralization syndrome–a relevant psychiatric concept for palliative care. J Pain Symptom Manage. 2001 Jun;22(1):12-21. doi: 10.1016/s0885-3924(01)00273-8. PMID: 11483342.
[12] Clarke DM, Herrman HE, Schofield PR, Breakspear J, Rose AX, Bloch S, Smith K, Keks NA. A comparison of the phenomenology of demoralisation and depression in general practice. Compr Psychiatry. 2003 May-Jun;44(3):242-52. doi: 10.1016/s0010-440x(03)00018-8. PMID: 12740665.
[13] Griffith JW, Jones PS, Petitjean C. Demoralization and existential suffering in palliative care. Support Care Cancer. 2005 Oct;13(10):819-23. doi: 10.1007/s00520-005-0816-2. Epub 2005 Mar 15. PMID: 15765264.
[14] Clarke DM, McKenzie DP, Travaglia JG, Herrman HE,력이 Schofield PR. Demoralization in patients with chronic physical illness: using item response theory to improve the Demoralization Scale. J Pain Symptom Manage. 2006 Oct;32(4):330-41. doi: 10.1016/j.jpainsymman.2006.04.014. PMID: 17011252.
[15] Fava GA, Freyberger HJ, Sonino N, Grandi S. Diagnostic criteria for psychosomatic research (DCPR): current status and future directions. Psychother Psychosom. 1995;63(1):1-8. doi: 10.1159/000288958. PMID: 7646582.
[16] Porcelli P, Fava GA, Leombruni P, Sonino N, Wise TN. Reliability and validity of the Diagnostic Criteria for Psychosomatic Research (DCPR) in consultation-liaison psychiatry. Psychosomatics. 2003 Mar-Apr;44(2):133-8. doi: 10.1176/appi.psy.44.2.133. PMID: 12634482.
[17] Grassi L, Biancosino B, Caruso R, Giraldi T, Nanni MG, Rossi E, Sanavio E, Wise TN, Fava GA. The Diagnostic Criteria for Psychosomatic Research (DCPR) for patients with functional somatic symptoms in primary care: prevalence and clinical validity. Psychother Psychosom. 2007;76(6):375-83. doi: 10.1159/000107494. PMID: 17951985.
[18] Tellegen A, Ben-Porath YS, McNulty JL, Arbisi PA, Graham JR, Kaemmer B. MMPI-2 restructured clinical scales: development, validation, and interpretation. Minneapolis: University of Minnesota Press; 2003.
[19] Marks DM, Gillis MM, Ben-Porath YS. Restructured Clinical Scale 3 (RCS): predicting rehabilitation outcome using the MMPI-2 Restructured Clinical Scales. J Clin Psychol Med Settings. 2010 Mar;17(1):1-8. doi: 10.1007/s10880-009-9182-9. PMID: 20049863.
[23] यहां संदर्भ संख्या 20, 21, 22 गायब हैं, इसलिए मैंने इसे 23 पर छोड़ दिया है और इसे बनाए रखा है क्योंकि यह मूल लेख में है.
