Demoralization Scale Research Articles

Symptom burden, loss of dignity, and demoralization in patients with cancer: a mediation model

Demoralization is a syndrome of existential distress that occurs in a substantial minority of cancer patients and is associated with a higher number of physical problems. Loss of dignity refers to a range of specific existential concerns. This study examines whether the association between number of physical problems and demoralization is mediated by loss of dignity. This cross-sectional study examined N = 112 inpatients with mixed tumor sites at early and advanced disease stages using the following standardized self-report questionnaires: Physical problems list of the National Comprehensive Cancer Network (NCCN) Distress Thermometer (DT), Patient Dignity Inventory (PDI), Demoralization Scale (DS), Patient Health Questionnaire-9 (PHQ-9) and Illness-Specific Social Support Scale Short Version-8 (ISSS-8). The mediation hypothesis was tested by multiple regression analyses controlling for age, gender, curative versus palliative treatment phase, and social support. Patients reported M = .7 (SD = 6.0) dignity-related problems; 20% showed moderate to severe demoralization. Loss of dignity significantly mediated 81% of the effect of the number of physical problems on demoralization (Sobel zs = 4.4, p < .001). Testing the reverse direction, we found that demoralization mediated only 53% of the association between physical problems and loss of dignity (zs = 3.7, p < .001). By supporting the mediation hypothesis, our results indicate that loss of dignity partially explains the association between physical problems and demoralization. Early recognition of dignity-related existential concerns and interventions to enhance the sense of dignity may prevent demoralization in patients with cancer. Results provide a conceptual link between existential concerns (loss of dignity) and existential distress (demoralization) as two approaches to existential suffering in patients with cancer.

The MMPI–2–RF Personality Psychopathology Five (PSY–5–RF) Scales: Development and Validity Research

This article describes the development, internal psychometric, and external validation studies on scales designed to measure the Personality Psychopathology Five (PSY–5) from MMPI–2 Restructured Form (MMPI–2–RF) items. Diverse and comprehensive data sets, representing various clinical and nonclinical populations, were classified into development and validation research samples. Item selection, retention, and exclusion procedures are detailed. The final set of PSY–5–RF scales contain 104 items, with no item overlap between scales (same as the original MMPI–2 PSY–5 scales), and no item overlap with the Demoralization scale. Internal consistency estimates are comparable to the longer MMPI–2 PSY–5 scales. Appropriate convergent and discriminant validity findings utilizing various self-report, collateral rating, and record review data are reported and discussed. A particular emphasis is offered for the unique aspects of the PSY–5 model: psychoticism and disconstraint. The findings are connected to the broader PSY–5 literature and the recommended review of systems (Harkness, Reynolds, & Lilienfeld, this issue) presented in this series of articles.

Receiving Palliative Treatment Moderates the Effect of Age and Gender on Demoralization in Patients with Cancer

BackgroundExistential distress is an important factor affecting psychological well-being in cancer patients. We studied occurrence and predictors of demoralization, a syndrome of existential distress, in particular the interaction of age, gender, and curative vs. palliative treatment phase.MethodsA cross-sectional sample of N = 750 patients with different tumor sites was recruited from in- and outpatient treatment facilities. Patients completed the following self-report questionnaires: Demoralization Scale, Patient Health Questionnaire-9, Illness-Specific Social Support Scale Short Version-8, and physical problems list of the NCCN Distress Thermometer. Moderated multiple regression analyses were conducted.ResultsWe found high demoralization in 15% and moderate demoralization in 8% of the sample. Curative vs. palliative treatment phase moderated the impact of age and gender on demoralization (three-way interaction: b = 1.30, P = .02): the effect of age on demoralization was negative for women receiving palliative treatment (b = −.26, P = .02) and positive for men receiving palliative treatment (b = .25, P = .03). Effects of age and gender were not significant among patients receiving curative treatment. Female gender was associated with higher demoralization among younger patients receiving palliative treatment only. Analyses were controlled for significant effects of the number of physical problems (b = 6.10, P<.001) and social support (b = −3.17, P<.001).ConclusionsExistential distress in terms of demoralization is a relevant problem within the spectrum of cancer-related distress. It is associated with a complex interaction of demographic and medical patient characteristics; existential challenges related to palliative treatment may exacerbate the impact of age- and gender-related vulnerability factors on demoralization. Psychosocial interventions should acknowledge this interaction in order to address the individual nature of existential distress in subgroups of cancer patients.

Is the degree of demoralization found among refugee and migrant populations a social-political problem or a psychological one?

Background and Objectives: Many international studies point to the negative impact of migration on refugee mental health while others consider the social and political aspects of resettlement are more important. This paper presents the findings from studies examining the degree of demoralization and the impact of other factors on resettlement among three cohorts of resettled refugees and migrant people residing in Australia, Canada and New Zealand. The aims were to determine: participant levels of demoralization; ascertain if the goals contained in the New Zealand Immigration Settlement Strategy are achievable and whether the lack of such goals impacted on participant levels of demoralization. Methods: Study questionnaires, standardized inventories, focus groups, individual semistructured interviews, and a demoralisation scale were completed by three different cohorts of refugee and migrant people attending mental health and resettlement services in Australia, Canada and New Zealand. The data was analyzed using statistical and thematic analysis. Results: While a degree of demoralization was evident across all cohorts significant differences (p < 0.01) were found between mental health participant scores in comparison to non-clinical cohorts. Factors such as an ability to speak English (p < 0.01) and unemployment (p < 0.001) also significantly impacted on the demoralization mean scores. Conclusions: The findings support the view that social and cultural issues play a role in understanding the degree of psychological distress among culturally diverse clients. Thus, in order to reduce the risk, additional factors associated with migration that may impact on resettlement need to be taken into account.

Introduction of the demoralization scale in Hungary, a study on demoralization and depression among hospice patients

Depression is a common problem among hospice patients. In the past few years, the international literature has dealt with demoralization, which is a new phenomenon. According to clinical studies, it give a better description of the patients' state in palliative care than depression. In Hungary there has been no research performed on demoralization yet. The aim of the authors was to introduce the demoralization scale in Hungary, learn about its practical use, as well as to study and compare demoralization and depression. The Hungarian translation of the demoralization scale and the short form of the Beck depression inventory were applied in the institutional and home hospice service in Pécs. The rate of the patients with severe demoralization but no depression was 10.5-21%. According to the severity of the demoralization, the rate of severely demoralized patients was 37-53%. Patients who suffered from pain or severe physical problems were significantly more demoralized and depressed. In hospice patients, demoralization occurs in a higher rate than depression. The demoralization scale is suitable for describing patients' feelings and thoughts. The relief of their physical symptoms affects their emotional state. The authors introduced the demoralization scale in Hungary which can be a good tool for psychological management in palliative care.

Preliminary evaluation of the reliability and validity of the Shame and Stigma Scale in head and neck cancer

Facial disfigurement from head and neck cancer can lead to the development of shame and a perception of stigma. We sought to develop the Shame and Stigma Scale (SSS) to measure this. Items were administered to 104 patients with squamous cell carcinoma of the oral cavity, together with measures of quality of life and adaptation. Exploratory factor analysis and item response theory (IRT) models assessed its psychometric properties. A 20-item SSS had a Cronbach's alpha of 0.94 and 4 factors: shame with appearance, sense of stigma, regret, and speech/social concerns. These factors show satisfactory internal validity, convergent validity with the Functional Assessment of Cancer Therapy-General (FACT-G) and Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N), Demoralization Scale and Patient Health Questionnaire (PHQ) Depression, and divergent validity with the Social Desirability Scale. The items displayed desirable properties in factor-specific (IRT) models. Further validation studies are worthwhile to confirm this factor structure, reliability, and validity, and generalizability to all head and neck cancers.

Demoralization syndrome among cancer outpatients in Taiwan

This paper aims to explore characteristics of demoralization syndrome as well as the relationship between demoralization syndrome and psychosocial issues as seen through examinations of cancer outpatients in Taiwan. Outpatients with different cancer types were enrolled in this study. The Demoralization Scale Mandarin Version (DS-MV), Patient Health Questionnaire, Beck Hopelessness Scale, and McGill Quality of Life Questionnaire-Taiwan Version were used as instruments. All data were analyzed using SPSS 18.0. Among the 234 patients studied (97 men and 223 women), the majority had cervical cancer (29.1%), followed by breast cancer (26.5%) and head and neck cancer (24.3%). The mean score of DS-MV was 31.05 (SD 14.87). The results of ANOVA analysis showed a significant effect of occupation F(4.209) = 7.145 (p < 0.001), cancer diagnosis F(7.206) = 3.795 (p < 0.001), and treatment F(8.206) = 3.553 (p < 0.001) on DS-MV. Demoralization syndrome was found to be related to psychosocial issues, different cancer types, and treatments. Further studies are recommended to better understand causes and impacts of demoralization in the quality of life and care of cancer patients.

Demoralization and Depression in Patients With Advanced Cancer: Validation of the German Version of the Demoralization Scale

Context The concept of demoralization has been widely used to describe states of existential distress and a self-perceived incapacity to deal effectively with a specific stressful situation. Objectives To evaluate the psychometric properties of the German adaptation of the Demoralization Scale (DS) in patients with advanced cancer. Methods Participants with heterogeneous tumor sites were recruited in several treatment and rehabilitation facilities. Concurrent and divergent validity of the DS was analyzed through associations with and group differences between measures of distress, depression, anxiety, and meaning-related life attitudes. Results From a total sample of 1102 patients, 516 individuals (45%) with advanced cancer were enrolled (male 53%, median age 58 years [range 18–88], breast cancer 21%, prostate cancer 17%). The total mean score of the DS was 29.8 (SD = 10.41). Four factors were extracted by exploratory factor analysis, which accounted for 59% of the variation (Cronbach α = 0.84): loss of meaning and purpose (α = 0.88), disheartenment (α = 0.88), dysphoria (α = 0.80), and sense of failure (α = 0.76). DS dimensions shared between 12% and 62% of the variance. Demoralization was significantly associated with anxiety ( r = 0.71), depression ( r = 0.61), and distress ( r = 0.42). Fifty-seven percent of patients had high distress, 24% depression, and 11% high anxiety. According to different cutoff values, between 16% and 39% were seriously demoralized and 73% had moderate levels of demoralization. Between 5% and 20% of patients were seriously demoralized but not clinically depressed; 60% of patients with moderate levels of demoralization had no depression. Conclusion Results provide further evidence that the DS is a valid and reliable instrument of high clinical relevance in patients with advanced cancer.

P03-411 - The mental health consequences of protracted asylum seeking in Australia

The mandatory detention of asylum seekers in Australia and the administrative, legal and ministtreal appeal processes have lead to protracted process of refugee determination.Further compounding of trauma/ torture, diminished sense of self future and purpose leading to high levels distress including anxiety depressive and somatoform disorders. High levels of distress appear to persisit after refgugees are settled.Study/methods•Harvard Trauma Questionnaire-R (HTQ-R) •Hopkins Symptoms Checklist (HSCL-25) •Post-Migration Living Difficulties Checklist (PMLDC) •Psychiatric Epidemiology Research Interview - Demoralisation Scale (PERI-D)f •ResultsN = 124. 84% Male; 93% conversant in English •Age: 20–62 years (μ = 35 yrs, SD = 10.8) •Residency Status: PR n = 32 (25%) Asylum Seeker n = 92 (75%) •Visa status: BVE (30%) BVA (23%) Student Visa (10%) •Time since application: 0 – 178 months (14.8 yrs) (μ = 31.2, SD = 48.4) •Not economic refugees. &gt; 99% arrived by plane. • 34% without Medicare &amp; 23% no work rights.ConclusionMultiple fold higher than the general population. -Highly traumatised population -Marginal reduction when granted protection •Inter-correlation between clinical measures à indicates pan-distress. •Clinical measures with number of rejections &amp; time since app •Comparable number of pre-migration traumas yet difference in ‘refugee’ trauma &amp; PTSD for AS vs. PR may reflect that current state of trauma is due to RDP ∨ perpetuating psychosocial factors •It has characteristics of many disorders but its own identity lication à weak association. -Ceiling effect of distress? -current state of trauma is due to RDP &amp;/or perpetuating psychosocial factors •It has characteristics of many disorders but its own identity.

Is advanced cancer associated with demoralization and lower global meaning? The role of tumor stage and physical problems in explaining existential distress in cancer patients

This longitudinal study examines the extent to which global meaning, existential distress in terms of demoralization, and depression are predicted by tumor stage (UICC stages 0-II vs III/IV), palliative treatment, and physical problems in cancer patients. N = 270 cancer patients were studied at baseline (T1, response rate: 41%) and after 3 months (T2) (N = 178, 72%). The following standardized self-report measures were used: Demoralization Scale, Life Attitude Profile--Revised, Hospital Anxiety and Depression Scale, NCCN DT (physical problems list). Multivariate regression analyses controlling for sociodemographic variables showed the number of physical problems significantly predicting higher demoralization (β = 0.42, p<0.001) and depression (β = 0.34, p<0.001), but not global meaning. While palliative treatment intention was related to higher depression (β = 0.21, p = 0.03) and higher demoralization (ns), there was no effect of tumor stage on dependent variables. The hypothesized moderating effect of global meaning on the relation between physical problems and depression or demoralization, respectively, was not found. Results indicate a risk of existential distress in cancer patients across all disease stages, possibly due to confrontation with, albeit different, existential stressors throughout the illness. The general protective effect of global meaning against distress, independent of the number of physical problems, underscores the notion of existential concerns being relevant to cancer patients more generally, rather than just to a subgroup. However, physical problems might play a central role in the process of becoming demoralized through impairing the sense of mastery and competence. Findings finally strengthen the difference between the concepts of demoralization and global meaning.

Relative practical utility of the Minnesota Multiphasic Personality Inventory–2 Restructured Clinical Scales versus the Clinical Scales in a chronic pain patient sample

The Minnesota Multiphasic Personality Inventory–2 (MMPI–2) Restructured Clinical (RC) Scales comprise the core of the new MMPI–2 Restructured Form. They were developed to retain the familiar clinical descriptive characteristics of the original basic scales while correcting a number of major psychometric shortcomings. The resulting scales are intended to be more unidimensional and unique, with improved convergent and discriminant validity. These improvements should be most evident in client samples where the traditional scales yield global and diffuse elevations, interpretively very challenging to the clinician. In the present study the RC Scales were compared to the traditional Clinical Scales in differentiating depressed (n = 239) versus nondepressed (n = 77) neuropsychology outpatients, all of whom experienced chronic pain, and most also reported other syndromes. Multiaxial diagnoses were assigned by practicing clinicians using a variety of data sources, including MMPI–2 Clinical Scales but not the RC Scales. Whereas both sets of scales achieved good overall classification rates of about 85%, the RC Scales did so using significantly fewer scales, yielding a more focused, efficient, and clinically useful profile. In the depressed group, 7 of the 8 basic scales (which exclude Scales 5 and 0) were clinically elevated, whereas only 2 of the 8 RC Scales were elevated (in addition to the demoralization scale RCd). These findings offer significant implications for the psychological assessment of chronic pain patients.

Global meaning and meaning-related life attitudes: exploring their role in predicting depression, anxiety, and demoralization in cancer patients

While significance of the concept of meaning in understanding adaptation to cancer is widely accepted, it has been little studied, especially in longitudinal data. This study aims to clarify the role of global meaning and meaning-related life attitudes (death acceptance and goal seeking) in predicting different aspects of psychological and existential distress by reference to a specified research model. At baseline (T1), a sample of 270 cancer patients was recruited. Data from 178 patients could be obtained after 3 months at T2. Patients completed the Life-Attitude-Profile-Revised assessing global meaning and meaning-related life attitudes, the Hospital Anxiety and Depression Scale, and the Demoralization Scale. Hierarchical regression analyses were carried out in two steps. Sociodemographic and physical factors were controlled. Global meaning emerged as a significant negative predictor of depression (β = -0.27) (p ≤ 0.001) and demoralization (β = -0.27) (p ≤ 0.001). Death acceptance was a predictor of anxiety only (β = -0.21) (p ≤ 0.003), whereas goal seeking was a positive predictor of depression (β = 0.29) (p ≤ 0.001), anxiety (β = 0.36) (p ≤ 0.001), and demoralization (β = 0.35) (p ≤ 0.001). Findings confirm a global sense of meaning as an important protecting factor regarding the development of distress symptoms. Results suggest that different dimensions of meaning contribute to different dimensions of psychological well-being, as they refer to different existential problems. The need for and relevance of meaning-focused interventions in cancer patients is strengthened.

Development of the Remoralization Scale

Remoralization is the process of restoration of morale. Remoralization constitutes an important step in the therapeutic change process. Because no appropriate self-report instrument was available to indicate the level of morale in mental health care, the Remoralization Scale (RS) was developed. In a first study (299 outpatients), a pool of 69 items was examined to produce an initial scale with 16 items with a unidimensional factor structure. In a second study (199 outpatients, 192 nonpatients), the unidimensionality and scalar invariance of the initial scale was tested. To make the RS as short and easy to complete as possible, four items with low factor loadings were removed. In a third study (124 students), the test-retest reliability (r = 0.89) and internal consistency (α = 0.91) of the RS were estimated. In a fourth study, the construct validity of the RS was investigated using a demoralization scale (r = –.72) and scales that measure anxiety (r = –.52), depression (r = –.50), somatic symptoms (r = –.36), and social dysfunction (r = –.37). In a fifth study (23 panic outpatients), the sensitivity of the RS to therapeutic change was examined and found to be good. In closing, limitations of the RS are discussed.

Validation of the Demoralization Scale in an Irish advanced cancer sample

This article presents a validation study of the Demoralization Scale, a 24-item, 5-point response questionnaire developed by Kissane et al. in 2004 to assess demoralization in advanced cancer patients. One hundred Irish inpatients with advanced palliative cancer completed the Demoralization Scale and measures of depression, hopelessness, quality of life, and personal hopefulness. Principal component analysis of the Demoralization Scale yielded four similar factors found by Kissane et al. (2004), namely, loss of meaning, dysphoria, disheartenment, and sense of failure. A new factor, the hopelessness factor, was also found in the current study. The reliability of the five factors was good, ranging from .72 to .93. Contrary to the findings of Kissane et al.'s (2004) study, divergent validity of the Demoralization Scale was not supported. Demoralized patients were significantly more likely to be depressed than those that did not score highly on the Demoralization Scale. In addition, this study found significantly lower levels of demoralization in general compared with Kissane et al.'s (2004) study. The results of the current study show that, in an Irish palliative care context, demoralization is not differentiated from depression. Additional factor analytic studies are needed to validate the Demoralization Scale.

A Double-Blind Randomized Trial of Mood Stabilizer Augmentation Using Lamotrigine and Valproate for Patients With Schizophrenia Who Are Stabilized and Partially Responsive

To compare the efficacy of mood stabilizer augmentation of an antipsychotic for patients with schizophrenia who are both stabilized and partially responsive. Adult patients who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for schizophrenia or schizoaffective disorder were enrolled in a 12-week, double-blind randomized trial. Patients were stabilized on an antipsychotic, and dose remained constant. Patients were randomly assigned to 1 of 3 adjunctive treatments: (1) with lamotrigine, (2) with divalproex sodium, or (3) with placebo. Efficacy assessments included the Positive and Negative Syndrome Scale, the Calgary Depression Scale for Schizophrenia, a Demoralization Scale, and the Clinical Global Impression severity and improvement scores. The Lehman quality of life improvement scale was used to assess quality of life and social functioning. Ratings were done at each study visit, including the last visit when they had been tapered off the adjunctive treatment. There were no differences in global outcomes, symptoms, quality of life, or demoralization among the 3 groups. Short-term adverse effects were minimal. Augmenting antipsychotics with the mood stabilizers of lamotrigine or divalproex sodium for most partially responsive patients with chronic schizophrenia did not seem to be a useful treatment strategy for improving the residual symptoms. The small sample size limits firm conclusions.

Comparison of the MMPI-2 Restructured Demoralization Scale, Depression Scale, and Malingered Mood Disorder Scale in Identifying Non-credible Symptom Reporting in Personal Injury Litigants and Disability Claimants

A known groups design compared the ability of the 24-item MMPI-2 Restructured Clinical Demoralization Scale (RCd), the 57-item Depression Scale (Scale 2), and the 15-item Malingered Mood Disorder Scale (MMDS) to identify non-credible symptom response sets in 84 personal injury litigants and disability claimants compared to 77 non-litigating head-injured controls. All three scales showed large effect sizes (>0.80). Scale 2 was associated with the largest effect size (2.19), followed by the MMDS (1.65), and the RCd (0.85). Logistic regression analyses revealed that a cutscore of ≥28 on the 57-item Scale 2 was associated with high specificity (96.1%) and sensitivity (76.2%), while a cutscore of ≥16 on the 24-item RCd was less accurate (87% specificity and 50% sensitivity). Cutscores for the MMDS were not calculated as they were reported in a previous study. Results indicated that like the 15-item MMDS, the 57-item MMPI-2 Scale 2 may provide another empirically derived index with known error rates upon which examiners may rely to investigate hypotheses relative to exaggeration of illness-related behavior and impression management in forensic contexts involving PI litigants and disability claimants.

Genetic variation and covariation in the original and restructured clinical scales of the MMPI.

The authors investigated genetic variation and covariation among the original Minnesota Multiphasic Personality Inventory clinical and validity scales and the restructured clinical scales. Variation in most of these scales was best explained by a combination of moderate genetic influences and environmental influences not shared by cotwins. Genetic correlations among the standard clinical scales were generally substantial and positive (M = .48), whereas genetic correlations between the clinical scales and the K scale were strong and negative. The restructured clinical scales were strongly correlated with the general Demoralization scale (M = .55), with lower genetic correlations among the remaining scales (M = .39).

Socio-demographic and clinical features associated with demoralization in medically ill in-patients

In the present study we tried to identify which socio-demographic and clinical characteristics are associated with demoralization in medically ill in-patients. Patients (n. 296), consecutively admitted to medical wards in a 120 day period, were evaluated with the Demoralization Scale of the Psychiatric Epidemiological Research Interview (PERI-D) to assess demoralization , with the Mini International Neuropsychiatric Interview (MINI) to assess mental disorders (DSM-IV), with the Brief Disability Questionnaire for the evaluation of the functional disability, with the Duke Severity of Illness to assess severity of the medical illness. Moreover, the family support and threatening life events were also evaluated. A significant effect in increasing the demoralization score was observed for presence of Major Depression or Adjustment Disorder, poor family support, severity of functional disability, number of threatening life events in the past year and female gender. Major Depression needs to be recognized in demoralized medically ill in-patients, because it is one of the most important conditions associated with demoralization, which successfully responds to adequate treatment.

Sense of coherence as a protective factor for demoralisation in women with a recent diagnosis of gynaecological cancer

Demoralisation is a dysphoric mood state commonly seen in the medically ill. Its core features comprise hopelessness, helplessness, loss of purpose and meaning, despair, and existential distress. Sense of Coherence (SOC) is a quantifiable dispositional orientation that captures the character traits likely to protect against demoralisation. In this study, we hypothesised on theoretical grounds that a strong SOC would be associated with lower levels of demoralisation in the context of gynaecological cancer (GC). One hundred and twenty women with a recent (<12 months) diagnosis of GC were recruited from outpatient clinics. Participants were interviewed and completed questionnaire measures of demoralisation and SOC. A multiple regression analysis was performed using the five subscales of the Demoralisation Scale as predictor variables and SOC as the dependent variable. Together, the five subscales of the Demoralisation Scale accounted for 60% of the variance in SOC. The results supported the hypothesis, suggesting that SOC may be protective against demoralisation in the context of serious illness. Larger, multivariate studies that examine additional variables (such as coping) would be required to further clarify the relationship between SOC and demoralisation. In the meantime, clinicians may want to consider efforts to enhance SOC in patients.

Anticipatory Stress in the Population Facing Forced Removal From the Gaza Strip

The Israeli government decided in March 2005 to remove the settlers of the Gaza Strip, a process known as "disengagement." One person per household residing in 13 settlements was randomly selected for a telephone interview that included the Demoralization Scale of the Psychiatric Epidemiology Research Interview. Women respondents and those with fewer years of education, higher risk perception, greater alienation from government, poorer perceived health, no social support outside the West Bank or Gaza, worse religious coping, and residence in a secular settlement had enhanced risk for higher emotional distress. Positive current satisfaction with life was associated with greater place attachment, less risk perception, stronger ideological stand, less feeling of alienation from the government, a more positive view of the future, and plans to return to Gaza. This population, as others in transitional states, may be at risk for emotional distress compared with some but not all stable Israeli groups.