Subjective Incompetence Research Articles

A tale of two constructs: combined assessment of demoralization and subjective incompetence

ABSTRACT Demoralization comprises multiple dimensions. Among them, Subjective Incompetence (SI) is the perception of being incapable of appropriate action in demanding circumstances. SI may be an early sign of demoralization preceding hopelessness, thus we aimed at integrating items related to Subjective Incompetence into the clinical assessment of demoralization. We assessed 414 subjects from the general population with the Demoralization Scale, 24 items (DS24) and the Subjective Incompetence Scale, 12 items (SIS12). We used multiple approaches to detect the optimal number of factors and their item structure, then conducted Bayesian Item Response Theory analyses to study item psychometric properties. Item Response Theory models were used to extrapolate latent severity ratings of clinical dimensions. We modelled the DS24 with five factors (Disheartenment, Sense of Failure, Helplessness, Irritability, Loss of Purpose) and the SIS12 with three (Subjective Incompetence, Inability to plan, Inability to Deal). The more complex IRT model had the best predictive value and helped to identify the items with better discrimination properties across the different dimensions. Twenty items were retained and used to develop the combined Demoralization and Subjective Incompetence Scale (DSIS20), which maintained high correlation with raw and latent trait scores of the longer versions. We combined selected items of the DS24 and the SIS12 to develop the DSIS20, a shorter assessment instrument that includes Subjective Incompetence as well as other clinical dimensions of demoralization. Further study may clarify if DSIS20 may be helpful for the early detection of demoralization.

From Perceived Stress to Demoralization in Parkinson Disease: A Path Analysis.

ObjectivesThe objective of this study was to determine whether depression and anxiety are mediators between perceived stress and demoralization via a loss of the cognitive map to get out of the predicament manifesting as subjective incompetence.MethodsNinety-five consecutive outpatients with Parkinson's disease were evaluated for perceived stress, depression, anxiety, subjective incompetence, and demoralization using reliable and valid scales. Inclusion criteria were ages 40–90, intact cognition, and no current history of substance use. The setting was a Movement Disorders Clinic at a university-affiliated hospital. The outcome variable was demoralization, selected a priori. Mediators between perceived stress and demoralization were examined using path analysis.ResultsDepression, anxiety, and subjective incompetence were mediators between perceived stress and demoralization. Among all variables, subjective incompetence was the largest contributor to demoralization. Depression connected to demoralization indirectly via subjective incompetence (β = 0.25, p < 0.001), whereas anxiety bypassed subjective incompetence (β = −0.01, p = 0.882), connecting directly to demoralization (β = 0.37, p = 0.008).ConclusionEarly treatment and reversal of subjective incompetence and anxiety could potentially prevent the escalation of demoralization and the associated disruption in health-related quality of life and eventual suicide.

Mental state of demoralisation across diverse clinical settings: A systematic review, meta-analysis and proposal for its use as a ‘specifier’ in mental illness

Demoralisation is a state of poor coping characterised by low morale, hopelessness, subjective incompetence, and loss of meaning and purpose in life. While studied extensively in oncology and palliative care, there has been recent exploration in broader medical and mental health settings. The aim was to investigate the prevalence of demoralisation and associated sociodemographic and psychological factors across these clinical settings. Six electronic databases were used to locate articles from January 2014 to March 2020. A pre-publication update of non-oncology populations was completed in September 2021. The review has been reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled prevalence of demoralisation was determined through % prevalence and mean demoralisation score; this was synthesised through meta-analysis of single means to determine pooled mean prevalence of Demoralisation Scale scores using the 'R' statistical software. Demoralisation has been examined in 52 studies (n = 11,670) and found to be prevalent in 24-35% of oncology and non-oncology, including mental health, populations. The mean score on the Demoralisation Scale was 24.3 (95% confidence interval, CI = [21.3, 27.3]). There was evidence of divergent validity in addition to significant comorbidity between depression, demoralisation and suicidal ideation. Burdensome physical symptoms, and psychological and demographic factors are strongly correlated with demoralisation. There remains a need to recognise demoralisation in various clinical and cultural settings and to strongly consider its inclusion as a 'specifier' within formal nosological systems for adjustment and depressive disorders. This is important to initiate targeted interventions and prevent significant morbidity.

Historical and psychological analysis of the phenomenology of the experience of hopelessness: clinical and prognostic aspects

The results of the historical and psychological analysis of the phenomenology of the experience of hopelessness are presented and its clinical and prognostic aspects are specified. It is assumed that hopelessness may have both the nature of a mental state and a personality trait, and may contain both components simultaneously, and the carriers of "hopelessness-trait" are more vulnerable to "hopelessness-state". Hopelessness is seen as a factor that reduces a person's psychological security. Individuals with "hopelessness traits" tend to have negative expectations about many aspects of life, while those who experience hopelessness as a condition have such expectations about a limited number of areas of life. Clarity in the operationalization of these concepts (trait versus state) is lacking today, appropriate tools have not been developed. Close to the phenomenon of hopelessness (but not identical) is the construct of pessimistic attributive style (which to some extent "assimilated" the concept of locus of control), which has traditionally been seen as a cognitive risk factor for depression for both adults and children. An alternative view of hopelessness is to include it in a broader context - the phenomenon of demoralization. This construct describes such experiences as: helplessness, hopelessness, loss of meaning and purpose in life, existential despair; it has common symptoms with distress, but differs from depression in the presence of subjective incompetence and lack of anhedonia. Many, including long-term prospective, epidemiological studies have found that baseline hopelessness is significantly associated with suicidal ideation, attempted suicide, and completed suicide, with variables reflecting the frequency of psychiatric diagnoses. If we accept the hypothesis that the relationship between hopelessness and suicide is influenced by some third variables, it may mean the desirability of a clearer identification of those subgroups of suicides for whom hopelessness is a risk factor as much as possible. This possibility of isolating complex predictors can be a very useful guide in suicidal practice.

COVID-19 and Long-Term Care Healthcare Worker Mental Health in Rhode Island

IntroductionHealthcare workers in long-term care settings and group homes for the disabled are at signi?cant risk of contracting COVID-19 and subsequently infecting the residents, fellow co-workers, and their family. In addition, lower paying long-term care healthcare workers maybe working multiple jobs which increases the risk of exposure. In April 2020, 27% of all deaths in the population was among residents in long-term care. The elderly population has the greatest risk for mortality from COVID-19 (Liu et al. 2020) and are disproportionality a?ected by social distance and self-isolation. Most long-term care settings have implemented lockdowns preventing families from visiting and limiting interactions among residents. Social isolation of the elderly is considered a serious public health concern. Social disconnection is a risk factor for increased depression and anxiety among the elderly. It is hypothesized that elderly persons are at high risk for poor mental health outcomes from the COVID-19 pandemic. The Alzheimer's Disease International suggest that those with dementia “may become more anxious, angry, stressed, agitated, and withdrawn during the outbreak”. These factors potentially may increase stress on healthcare workers in long-term care settings beyond the fears of exposure and transmitting COVID-19 to their families. There are few studies to date that examine the mental health impact of COVID-19 on healthcare workers in long-term care. The United Nations has highlighted the mental health risk to workers in long-term care. “First responders and front line workers, particularly workers in health and long-term care play a crucial role in ?ghting the outbreak and saving lives. However, they are under exceptional stress, being faced with extreme workloads, di?cult decisions, risks of becoming infected and spreading infection to families and communities, and witnessing deaths of patients.”MethodsHealthcare workers in long-term care facilities, and assisted living facilities in Rhode Island were given questionnaires to complete that examined mental health and risk factors associated with COVID-19. The questionnaire includes items on the healthcare worker's experience with COVID-19. Resilience is measured using The Brief Resilience Scale assessing the individual's ability to bounce back or recover from stress. Subjective incompetence is de?ned as the perceived incapacity to perform tasks and express feelings deemed appropriate in a stressful situation. Increasing distress and subjective incompetence may convert a normal reaction to stress into mental disorder requiring intervention. Demoralization is measured using the Demoralization Scale-II. Depression and anxiety is measured using two of the most commonly used screens in clinical care, the PHQ-9 for depression and the GAD-7 for generalized anxiety. Family functioning during and before the COVID-19 pandemic is measured using the three-item Brief Assessment of Family Functioning. Social support is measured during and before the COVID-19 pandemic using the emotional-informational support subscale of the Brief Social Support Scale derived from the Medical Outcomes Study Social Support Survey. Coronavirus Anxiety Scale is a mental health screener designed to aid in the identi?cation of probable cases of dysfunctional anxiety associated with the COVID-19 pandemic. The fear of Coronavirus-19 Scale was used to measure this construct. The ?ve-item Primary Care PTSD Screen was adapted to COVID-19 as a traumatic event. Items measuring healthcare worker workplace stress was developed based on a items from a number of existing scales. A 15-item health care workers attitudes toward the management of COVID-19 in the long-term care facility was developed by the research team that focuses on training of sta?, safety, and resident care.ResultsPreliminary data will be presented. Data collection is currently underway. There are 65 assisted living facilities and 85 nursing homes in Rhode Island. Approximately 10% of the facilities are currently participating with the aim to recruit nearly all facilities in the state.ConclusionsThe hypotheses to be tested is that healthcare workers in long-term care settings have mental health issues including demoralization, depression and anxiety due to the COVID-19 pandemic disaster. That those who are in facilities with COVID-19 residents have increased stress. Those facilities that have placed increased demands on healthcare workers will have employees that are having more difficulty in dealing with the COVID-19 pandemic. This study examines how healthcare workers in long-term care facilities have coped during the COVID-19 pandemic and the impact on their mental health; factors that protect or place the healthcare worker at risk for poorer mental health outcomes (depression, anxiety, demoralization, post-traumatic stress); and factors during COVID-19 that place the healthcare worker for poorer mental health outcomes during COVID-19 pandemic.FundingDepartment of Psychiatry of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Lifespan

Exploring and assessing demoralization in patients with non-psychotic affective disorders

BackgroundDemoralization, as assessed through the Diagnostic Criteria for Psychosomatic Research–Demoralization (DCPR/D) interview or the Demoralization Scale (DS), has been found to affect about 30% of patients with medical disorders, while few studies have been done in patients with psychiatric disorders. MethodsA convenience sample of 377 patients with ICD-10 diagnoses of mood, anxiety, stress-related disorders or other non-psychotic disorders was recruited from two Italian university psychiatry centers. The DCPR/D interview and the Italian version of the DS (DS-IT) were used to assess demoralization and the Patient Health Questionnaire-9 (PHQ-9) to assess depression. ResultsDemoralization was diagnosable in more than 50% of the patients. Factor analysis of the DS-IT indicated four main factors, Meaninglessness/Helplessness, Disheartenment, Dysphoria and Sense of Failure, explaining 62% of the variance of the scale. Patients with bipolar or unipolar major depression and personality disorders had the highest prevalence of demoralization (DCPR/D) and the highest scores on all the DS-IT factors in comparison with patients with adjustment or anxiety disorders. About 50% of patients with moderate demoralization (DS-IT) were not clinically depressed (PHQ-9 <10), while almost all with severe demoralization were depressed. LimitationsProspective studies on larger samples with other psychiatric disorders, also taking into account subjective incompetence, are needed. Since the DCPR/D assesses demoralization as a categorical construct, a dimensional framework should be necessary. ConclusionsThe findings enrich the research on demoralization, showing for the first time the importance of this construct, as measured by the DCPR/D and the DS-IT, in patients with psychiatric disorders.

Demoralization and associated features in an Italian sample of end-of-life cancer patients.

e23004 Background: Demoralization is an expression of cancer-related existential distress that emerges from feelings of loss and changes linked to a life-threatening clinical condition. It is characterized by subjective incompetence, sense of failure, hopelessness, loss of purpose/meaning and low self-esteem. The study aimed to explore prevalence, latent dimensions and associated features of demoralization in a sample of end-of-life cancer patients. Methods: Participants were recruited for a cross-sectional assessment. For each patient, demoralization, anxiety, depression, physical symptoms, pain, spiritual well-being, and dignity were evaluated through validated rating scales and personal and medical data were gathered by a clinician. Final sample consisted of 235 end-of-life cancer patients with a Karnofsky Performance Status (KPS) lower than 50 and a life expectancy of few weeks. Results: High levels of demoralization occurred in 22.6% (n = 53) of patients. Sixty-four participants (27.2%) had low demoralization and 50.2% (n = 118) had moderate demoralization. Emotional Distress and Inability to Cope, Loss of Purpose and Meaning, Worthlessness, Sense of Failure and Dysphoria were the five latent dimensions of demoralization emerged from the factor analysis. Demoralization was significantly associated with depression, anxiety, dignity, spiritual well-being and the physical symptoms except for nausea and breathing problems. Conclusions: Demoralization levels seem to be higher in this distinctive population than in advanced cancer patients. This could be due to the fact that end-of-life cancer patients are in a severe clinical condition and nearing death. The emerged demoralization dimensions could be five forms of expression of the existential distress typical of this illness phase. The considerable number of patients suffering from demoralization strengthen the need for psychological interventions in order to reduce the existential distress at the end of life, focusing on finding meaning and detecting spiritual concerns.

Demoralization in essential tremor: prevalence, clinical correlates, and dissociation from tremor severity.

Essential tremor (ET) is associated with psychological difficulties, including anxiety and depression. Demoralization (feelings of helplessness, hopelessness, inability to cope), another manifestation of psychological distress, has yet to be investigated in ET. Our objectives are to (1) estimate the prevalence of demoralization in ET, (2) assess its clinical correlates, and (3) determine whether demoralization correlates with tremor severity. We administered the Kissane Demoralization Scale (KDS-II) and several psychosocial evaluations (ie, scales assessing subjective incompetence, resilience, and depression [eg, Geriatric Depression Scale]) to 60 ET subjects. Tremor was assessed with a disability score and total tremor score. KDS-II >8 indicated demoralization. Among 60 ET subjects (mean age = 70.2 ± 6.8 years), the prevalence of demoralization was 13.3%, 95% confidence interval = 6.9-24.2%. Although there was overlap between demoralization and depression (10% of the sample meeting criteria for both), 54% of depressed subjects were not demoralized, and 25% of demoralized subjects were not depressed. Demoralization correlated with psychological factors, but demoralized subjects did not have significantly higher total tremor scores, tremor disability scores, or years with tremor. Demoralization has a prevalence of 13.3% in ET, similar to that in other chronic or terminal illnesses (eg, cancer 13-18%, Parkinson's disease 18.1%, coronary heart disease 20%). Demoralization was not a function of increased tremor severity, suggesting that it is a separable construct, which could dictate how a patient copes with his/her disease. These data further our understanding of the psychological and psychosocial correlates of ET.

Author response: Demoralization in Parkinson disease.

I thank Bruno et al. for their comment on demoralization in Parkinson disease (PD). Certainly, it makes sense to explore feelings of hopelessness when studying demoralization, as hopelessness is more specific to demoralization than is depressed mood. I am curious if Bruno et al. found this to be the case in their PD cohort. It is interesting that their findings mirror ours,1 in that demoralization was associated with the Movement Disorders Society–sponsored revision of the Unified Parkinson’s Disease Rating Scale III. The finding that depression, but not demoralization, is associated with caregiver burden is interesting and also makes sense. Demoralization and depression are overlapping yet distinct feeling states. Demoralization is characterized by subjective incompetence and a loss of a cognitive map, but willpower remains. In depression without demoralization, the cognitive map is intact but willpower is gone. Social support and perceived social support are also important factors that safeguard against demoralization. I commend Bruno et al. for looking at the important issue of demoralization in PD and for having the foresight to include an assessment of the caregiver and his or her burden.

Advances in the Understanding of Demoralization in Oncology and Palliative Care

Over the last decade, psychosocially-oriented assessment methods, rather than nosological psychiatric systems, have been used in oncology and palliative care to detect clinically relevant dimensions with prognostic and therapeutic implications. Demoralization has emerged as one of the most important constructs, a clinical syndrome distinct from other psychiatric disorders (e.g., major depression, dysthymia, adjustment disorders, post-traumatic stress disorder [PTSD]). A number of recent studies have shown that demoralization in cancer patients is related to confrontation with existential stressors that impair the sense of mastery and competence of the individual throughout the illness and across all disease stages. Clinically, demoralization is characterized by feelings of subjective incompetence in dealing with stress, a sense of failure to meet the expectations of others, a sense of being trapped, accompanied with feelings of impotence, isolation, and despair, hopelessness or loss of meaning and purpose in life. Demoralization has a remarkable role in negatively influencing a patients’ quality of life, coping styles, and dignity and in increasing the risk for suicidal ideation. This article presents and discusses the most recent emerging issues related to demoralization in oncology and palliative care in terms of prevalence, diagnostic boundaries, and consequences to clinical practice. Important tools for the assessment of demoralization are also summarized and implications for future research are discussed.

Subjective incompetence as a predictor of treatment outcomes in eating disorder outpatients

Eating disorder (ED) patients are frequently characterized by feelings of inefficacy. The aims of the present study were to investigate subjective incompetence and whether its early modification in therapy is associated with treatment response in terms of both psychological distress and well-being. Sixty female ED outpatients undergoing cognitive-behaviorally-based treatment integrated with nutritional rehabilitation were evaluated using: Subjective Incompetence Scale (SIS), Eating Attitudes Test (EAT), Beck Depression Inventory (BDI-II), and Psychological Well-being Scales (PWB). Repeated measures analysis of variance to test changes in variables and hierarchical regression analyses to test the predictive role of SIS were conducted. Significant improvements in SIS, and in distress measures (EAT, BDI-II) and well-being (PWB) were observed by mid-treatment. Early SIS reductions in patients significantly predicted reductions in EAT-food and bulimic preoccupations, EAT-oral control and EAT-dietary restraint scores, independently of initial depressive symptomatology and illness severity. Gains in three PWB dimensions (environmental mastery, purpose in life, self-acceptance) were also predicted by changes in subjective incompetence. Treatment response might be enhanced by targeting more specifically persistent feelings of incompetence associated with ED symptomatology and compromised psychological well-being dimensions. Such paucities in positive functioning are central themes in EDs and if left untreated might represent obstacles to recovery.

Oskar Pfister Award Winner Offers Hope to the Demoralized

Oskar Pfister Award Winner Offers Hope to the Demoralized

Chronic Pain, Chronic Demoralization, and the Role of Psychotherapy

This article discusses demoralization in patients with chronic pain and the role of psychotherapy at combating chronic demoralization associated with chronic pain. The advantages of the biopsychosocial conceptual framework for the understanding of chronic pain are highlighted. Demoralization may be viewed as a combination of distress and subjective incompetence. While the distress experienced by the patient may be understandable and commensurate to the predicament, the co-occurrence of subjective incompetence (the polar opposite of resilience) and its escalation to helplessness, and hopelessness may result in suicidal attempts, demands for euthanasia, or death by suicide. The complexity of chronic pain and its relationship to demoralization may be examined from multiple perspectives. Biological, psychological, social and cultural variables play varying roles depending on the observer’s perspective and the context of the observation. The role of psychotherapy in chronic pain may be viewed in terms of multiple pathways through which language, cognitive style, behavior, relationships, attitude towards pain, and awareness of the body modify the relative influences of top-down and bottom-up processing of information within the pain neuromatrix. Various psychotherapeutic interventions developed for patients with chronic pain are reviewed and recommendations are made for future research.

Early postnatal demoralisation among primiparous women in the community: measurement, prevalence and associated factors.

BackgroundDemoralisation is a psychological state occurring in stressful life situations where a person feels unable to respond effectively to their circumstances, characterised by feelings of distress, subjective incompetence, helplessness and hopelessness. The period after the birth of a first baby is a time of great changes and disruptions to many aspects of the mother's physical, psychological and social functioning. This can lead to feelings of distress, a sense of incompetence and helplessness. This study aimed to examine: (1) the psychometric properties of the Demoralisation Scale in a community setting; (2) the prevalence of demoralisation symptoms among primiparous women in the community; and (3) factors that are uniquely associated with demoralisation in the early postnatal period.MethodsPrimiparous women attending community maternal health centres (n = 400) were recruited and administered the study's questionnaires through a telephone interview.ResultsThe Demoralisation Scale was found to be a reliable and valid tool among women in the community who had recently given birth. Higher levels of demoralisation were independently associated with lower confidence on going home from the hospital after birth, lower rating of mother's self-rated global health, more than 3 h of infant crying and fussing in the last 24 h, and a controlling partner, after symptoms of depression and anxiety, and vulnerable personality characteristics were controlled for.ConclusionsThe relevance of demoralisation to postnatal health practitioners in the community is in helping them to better understand women's experiences and to intervene in a way that is more meaningful and less stigmatising to women.

Postnatal demoralisation among women admitted to a hospital mother-baby unit: validation of a psychometric measure.

Demoralisation is a psychological state characterised by experiences of distress and sadness, helplessness, subjective incompetence and hopelessness, in the context of a stressful situation. Experiences of demoralisation may be particularly relevant to women who have recently given birth, who can feel incompetent, isolated and helpless. The psychometric properties of the Demoralisation Scale among women in the postnatal period participating in a clinical program were examined. Women admitted with their infants to a hospital mother-baby unit in Australia for five nights were recruited consecutively (N = 209) and assessed at admission and discharge. The Demoralisation Scale was perceived as relevant and exhibited high reliability, acceptable construct validity and good sensitivity to change. The mean demoralisation score was high (M = 30.9, SD = 15.5) and associated with negative experiences of motherhood and functional impairment, independent of depression and anxiety symptoms. Mean demoralisation decreased significantly after program completion (M = 18.4, SD = 12.4). More participants showed a significant improvement in demoralisation (57.5%) than in depression (34.8%) and anxiety (9.8%) symptoms. Demoralisation can provide a useful framework for understanding and measuring the experiences of women participating in postnatal clinical programs and in directing treatment towards helping women to acquire the necessary caregiving skills and increasing parental efficacy. The Demoralisation Scale is a useful clinical tool for assessing intervention effects.

Demoralization: a systematic review on its clinical characterization.

Demoralization has been described as a psychological state characterized by helplessness, hopelessness, a sense of failure and the inability to cope. We conducted a systematic review with qualitative data analysis following PRISMA criteria with the following aims: to review validated assessment instruments of the demoralization syndrome, report main findings regarding demoralization as measured by validated instruments that emerge in the literature, compare and report evidence for the clinical utility of the identified instruments. Utilizing the key word 'demoralization' in PubMed and PsycINFO databases, an electronic search was performed, supplemented by Web of Science and manual searches. Study selection criteria included the assessment of medical patients and use of instruments validated to assess demoralization. Seventy-four studies were selected. Four instruments emerged in the literature. Main findings concern prevalence rates of demoralization, evidence of discriminant validity from major depression, factors associated with demoralization and evidence of clinical utility. The instruments vary in their definition, the populations they aim to assess, prevalence rates they estimate and their ability to discriminate between different conditions. Nonetheless, demoralization appears to be a distinctive psychological state characterized by helplessness, hopelessness, giving up and subjective incompetence. It is not limited to life-threatening diseases such as cancer, but may occur in any type of clinical situation. It is associated with stress and adverse health outcomes. Studies addressing the incremental value of demoralization in psychiatry and psychology are needed. However, demoralization appears to entail specific clinical features and may be a distinct condition from major depression.

Resilience and prevention of demoralization

The objective of this article is to describe a framework for the understanding of how the exchange of ideas and values between members of two different and conflicting cultures may lead to the prevention of demoralization and formation of a hybrid culture, and how this exchange may persist despite systematic opposition. Available evidence suggests that sociocultural resilience and individual resilience are pre-requisites of each other. Individual resilience appears to be the polar opposite of subjective incompetence, the clinical hallmark of demoralization. The testing of these hypotheses requires a longitudinal study of acculturation over a period of decades or centuries. This could be accomplished by interpreting social and cultural phenomena identified by historical research in terms of current evidence-based and integrated knowledge in psychiatry, psychology, epidemiology, sociology, and anthropology.

Distress, demoralization and psychopathology: Diagnostic boundaries

Background and Objectives: The objectives of the manuscript are: (a) to review the understanding of demoralization and its assessment; (b) to describe its clinical progression; (c) to explain the differences between demoralization and other form of psychological distress; (d) to propose a set of criteria for future research on demoralization. Methods: A MEDLINE search using the keywords distress, subjective incompetence, depression, demoralization, helplessness, hopelessness and psychopathology was conducted. This was supplemented by a manual search of the literature. Results: Demoralization can be distinguished from passing or transient distress, nonspecific distress, sub-threshold depression or anxiety, and certain mental disorders. Demoralization can be a risk factor for the manifestation of psychopathology, the prodromal phase of a mental disorder, or a trigger for exacerbation or recurrence of psychiatric distress symptoms. The domains of distress and demoralization are described and research diagnostic criteria for demoralization are presented. Conclusions: The scales discussed in this article differ in their time frames and have not yet been applied to the same population at the same time. The role of demoralization as a risk factor for mental disorders is just beginning to be understood. The domains and the diagnostic criteria for demoralization presented in this article need to be confirmed by epidemiological and empirical studies. Future research should continue to clarify its role in the pathogenesis of both mental disorders and physical illnesses and identify appropriate interventions for its arrest or prevention.

Existential inquiry: Psychotherapy for crises of demoralization

Background and Objectives: Existential inquiry is a focal psychotherapy tailored to address crises of demoralization. Demoralization refers to the helplessness, despair, and subjective incompetence that people feel when perceiving themselves to be failing their own or others� expectations for coping with adversity. Methods: Existential inquiry revives a demoralized person�s capacity for coping by eliciting accounts for how the person has sustained hope, communion with others, purpose, agency, commitment, courage, and gratitude when threatened by losses, traumas, or insecurities. Existential questions reveal emotional postures of vulnerability and resilience. They ask both how a person has been impacted by adversities and how he or she has prevailed against them. Existential inquiry rebuilds morale by mobilizing emotional postures of resilience that are grounded in core identities: What are my deep desires and commitments? To whom am I accountable? Who do I know myself to be, or wish to be? Results: Clinical vignettes illustrate how these questions can open conversations that rebuild morale. Conclusions: Existential inquiry can serve as an effective brief psychotherapy for countering demoralization.

Differentiation Between Demoralization, Grief, and Anhedonic Depression

Demoralization is a phenomenon in which a patient reaches a state of subjective incompetence, hopelessness, and helplessness that can lead to that devastating moment in which he or she feels the only recourse left is to give up. This article reviews the medical literature regarding the current understanding, importance, and impact of demoralization. In addition, using the key characteristics of demoralization, this article attempts to compare and contrast demoralization with anhedonia and grief.