Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
India

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It is common for human beings to feel overwhelmed and give up! This phenomenon is usually temporary and short-lasting, and most people bounce back. However, in a small proportion of people, especially those facing challenging life situations, this may be a persistent feeling requiring clinical attention. This is clinically understood as demoralization. According to the Cambridge dictionary, demoralization is understood as the “process of making someone lose confidence, enthusiasm, and hope.” Understanding demoralization in medical and psychiatric disorders is very important, as it is highly prevalent and often requires clinical attention.

In addition, the clinicians can also feel demoralized in dealing with the stress, and it is often considered a forerunner of burnout.[1] Unfortunately, the majority of the clinicians do not consider the clinical possibilities that are not covered by the recognized nosological systems; hence, these are either ignored or miscategorized. Demoralization is one such clinical condition.

The term “demoralization” was introduced in the psychiatric literature by Jerome Frank in the context of psychotherapy, irrespective of the psychiatric diagnosis.[2] He described it as a state of mind in which a person is deprived of spirit or courage, is disheartened, bewildered, and thrown into disorder or confusion.[2] The person experiences incessant feelings of subjective incompetency or failures to meet their expectations or those of others and cannot cope and solve the emergent problems. The core problem responsible for demoralization is the inability to cope, leading to feeling trapped and hopeless.[3] Hope is understood as one of the most fundamental aspects of life, and loss of hope precedes death.[3] Although the concept of demoralization was initially described in psychotherapy, later on, it has been understood and evaluated across various medical illnesses and psychiatric disorders.

In the context of medical illnesses, any physical illness or mental disorder can lead to demoralization. In the context of medical illnesses, demoralization is understood as the feeling of disempowerment (i.e., not able to perform at one's previous level of functioning) and a sense of futility (i.e., a feeling that the condition is never going to improve and hence the dysfunction is going to continue).[4] However, it is essential to note that demoralization in the context of medical illnesses is understood as a dimensional concept, varying from normal reaction to the illness to an impairing clinical phenomenon requiring attention.[4] Over the years, many authors have tried to describe the clinical features of demoralization. They have characterized it by features of anxiety, apprehension, low mood, distress or existential distress, sense of isolation, hopelessness, helplessness, low self-esteem, personal incompetence, loss of purpose or meaning of life, and inability to cope.[4] In terms of clinical characterization, demoralization is distinguished from depression by the presence of hedonic capacity.[3] It is suggested that the primary deficit in persons experiencing demoralization is the sense of incompetence that leads to uncertainty in the direction of action to be followed. In contrast, persons with depression have low motivation to follow any direction, even when they know the appropriate direction of action.[5]

As demoralization is not included in the commonly used diagnostic systems in psychiatry, i.e., Diagnostic and Statistical Manual (DSM) and International Classification of Diseases, a group of researchers formed an international consortium and developed the Diagnostic Criteria for Psychosomatic Research (DCPR) to assess the psychological distress that is seen in persons with various physical illnesses.[6] It listed 12 conditions, demoralization being one of them. According to the DCPR criteria, demoralization is characterized by the patient's awareness of having failed to meet their expectations (or that of others) or being unable to cope with some pressing problems; as a result, the patient experiences feelings of helplessness, hopelessness, or giving up; the feeling state is prolonged, generalized, and present for at least one month; and the feeling is closely preceded by the manifestations of a medical illness or exacerbation of its symptoms.[4],[7] In another effort to characterize the demoralization syndrome, Kissane et al.[8] proposed diagnostic criteria for demoralization in the context of palliative care. This included: The presence of affective symptoms of existential distress, which also include features of hopelessness or loss of meaning and purpose of life; cognitive features of pessimism, helplessness, sense of being trapped, a feeling of personal failure, or lacking a worthwhile future; lack of drive or motivation to cope differently; associated social alienation or isolation and lack of support; persistence of features for more than 2 weeks with fluctuation in emotional intensity and lack of presence of a major depressive or other psychiatric disorder as the primary condition.[9]

The development of structured scales has furthered the concept of assessing the phenomenon of demoralization. One of the commonly used scales is the demoralization scale (DS), a 24-item scale that has good psychometric properties and has been translated into many languages (Kissane et al., 2004).[9] The DS focuses on the demoralization state findings focusing on the past 2 weeks. The five factors of DS include dysphoria, disheartenment, loss of meaning and purpose, helplessness, and a sense of failure.[9] Other scales while have been designed to assess demoralization in the research setting include Dohrenwend's Psychiatric Epidemiology Research Interview-Demoralization Scale (PERI-D),[10] a scale based on the DCPR criteria[11], and the Minnesota Multiphasic Personality Inventory-2 Restructured Clinical Scale of Demoralization.[12] Some of the authors consider that these scales assess nonoverlapping aspects or varying stages of demoralization.[5] The PERI-D is a self-report 27-item scale that focuses primarily on nonspecific distress and measures both trait and state demoralization depending on the time frame considered for evaluation. The various dimensions included in PERI-D include sadness, hopelessness-helplessness, poor self-esteem, anxiety, dread, poor self-esteem, psychophysiological symptoms, confused thinking, and perceived physical health.[10] Structured interview based on the DCPR criteria includes 58 yes/no questions, which identifies 12 psychosomatic syndromes, with demoralization being one of them. It assesses demoralization as a state measure, considering the last 4 weeks.[11]

In the context of physical illnesses, demoralization has been extensively studied in malignancies.[13],[14] A systematic review that included information from 25 studies reported the prevalence of clinically significant demoralization to be 13%–18%.[14] A higher prevalence of demoralization was associated with poorly controlled physical symptoms, poor social functioning, being unemployed, being single, and insufficiently managed depression and anxiety.[14] Some studies also show that demoralization differs from depression.[13] Besides cancer, a high prevalence of demoralization has also been reported in patients with systemic lupus erythematosus[15] and patients who have undergone cardiac transplants.[16] Studies that have assessed the prevalence of demoralization using the DCPR criteria among medical patients with DSM diagnosis of adjustment disorder suggest that the prevalence varies from 28.8% to 39%, with the highest rates among inpatients referred to consultation/liaison services.[17] Demoralization has also been reported to be associated with adverse health outcomes, especially in patients with cardiac ailments in the form of a higher risk of cardiac death or rehospitalization,[18] higher episodes of acute rejection in patients with the cardiac transplant.[16] Demoralization has also been a prodromal symptom of cardiac events.[19],[20] In patients with cancer, demoralization has also been associated with more physical symptoms, poorer quality of life, and functioning.[9],[21],[22]

The concept of demoralization has also been evaluated in persons with mental disorders. Initial equivalent terminologies include social breakdown syndrome, noted among patients institutionalized for long for their chronic mental illness.[23] In recent years, some studies have also evaluated demoralization among patients with schizophrenia and suggest prevalence rates to be as high as 94%.[24],[25] In terms of factors associated with demoralization, available evidence suggests that higher levels of demoralization be associated with better insight, higher self-stigma, presence of psychotic symptoms, lower level of functioning, and suicidal behavior.[26] These preliminary findings suggest that there is a need to evaluate demoralization in patients with mental disorders too.

These findings suggest that clinicians should assess demoralization in the context of all the medical illnesses and psychiatric disorders. Demoralization can be characterized by any one of the currently available criteria or scales. While assessing demoralization in a medical setting, depression and adjustment disorder must be considered differential diagnoses.

Some of the authors have discussed the management strategies for demoralization in the context of medical illnesses. Management of demoralization in the context of palliative care involves providing continuity of care and active management of symptoms, exploring the attitude toward hope and meaning in life, balancing support for grief and promoting hope, encouraging a search for a new or renewed purpose and role in life, cognitive restructuring to address the negative beliefs, providing pastoral and spiritual support, encouraging connection with other and improving the family support, enhancing family support and review of treatment goals in the multidisciplinary team meeting.[8] Other treatment strategies in the context of various medical illnesses include supportive, empathetic listening by the health-care providers and cognitive-behavioral techniques.[27] Other authors emphasize the importance of providing psychological support using good interview skills to discern the existential themes of significant concern in the index patient and address the same.[28]

References