Years ago, when I was seeing a psychiatrist for complicated bereavement, she noted that I was “demoralized by physical symptoms,” but did not consider me clinically depressed. That’s because these are two separate syndromes. The DSM-V defines major depression (simplified here) as including depressed mood, most of the day, nearly every day; markedly diminished interests or pleasure; psychomotor agitation and depression; feelings of worthlessness or excessive guilt; diminished ability to think or concentrate; and recurrent thoughts of death. In everyday parlance, demoralization is the process of making someone lose confidence, enthusiasm and hope; to deprive a person of spirit, courage, or discipline; to reduce to a state of weakness or disorder. The demoralization syndrome, not an official diagnosis, is the collection of disturbing existential states associated with a failure to cope. The psychiatrist, Richard Shader, in his 2005 article, “Demoralization Revisited,” refers to it “a state in which one develops a sense of ineffectiveness in the face of repeated defeats” and “a state of despair, hopelessness, helplessness, and loss of meaning and purpose in life, accompanied by a sense of subjective incompetence.” Thus, the distinction between depression and demoralization is that the former is characterized by anhedonia while the latter, by a lost sense of efficacy.

A scale to assess demoralization (the DS-II) has been refined and revalidated. A 16-item self-report instrument, it has a more simplified response format than its 24-item predecessor and has been found to be more user-friendly in the advanced cancer setting. An even briefer scale, the SDS, has been developed with only 5 items, corresponding to the following factors: helplessness, disheartedness, loss of meaning, dysphoria, and sense of failure. Both scales have been shown to have strong psychometric properties.

Naturally, demoralization is observed in various medical conditions, such as cancer, Parkinson’s disease, and heart transplant. The preservation of morale may be a final buffer that protects individuals from the terror of dying and death in the face of progressive disease. In patients with advanced cancer, demoralization has been associated with higher symptom burden, less perceived support, and the emergence of anticipatory fears about pain and suffering, and burdening of loved ones

Demoralization is also common in Parkinson’s disease and is associated with motor dysfunction. In a recent study, demoralization but not depression was associated with motor dysfunction. Discordance in the presence of the two syndromes suggests that demoralization is not a simple marker of depression. Cognitive behavioral therapy rather than antidepressant medication is likely a more appropriate form of treatment for demoralization. In a 2011 study of cardiac transplant recipients, compared to non-demoralized patients, the demoralized patients were found to have more impairments in all the dimensions of quality of life, less psychological well-being, especially the components of environmental mastery and self-acceptance, and more severe anxiety, depressive symptoms, somatization, and hostility.

Demoralization has also been associated with suicidal behavior in various populations and conditions. A recent Italian study assessed the effect of the construct in suicidal patients who attended emergency departments. This was a cross-sectional study which examined the role of demoralization, helplessness, and depression on suicidal ideation and suicidal attempts. Demoralization was related to major depressive episodes, but it was confirmed to be a different and probably more sensitive construct for suicidal behavior, validating its specificity in relation to depression. The authors concluded that demoralization can improve suicidal behavior assessment in EDs, particularly among patients whose suicide risk can be unnoticed. Furthermore, demoralization was seen as representing a clinically useful concept to increase comprehension of the suffering of suicidal patient and a possible target for psychotherapeutic intervention.

In his 2013 article, “Existential Inquiry,” psychiatrist J.L. Griffith provides a detailed psychotherapeutic approach to the problem of demoralization, positing eight “existential postures” of vulnerability and resilience. (Vulnerability: confusion, isolation, despair, helplessness, meaninglessness, indifference, cowardice, resentment; and the corresponding factors for Resilience: coherence, communion, hope, agency, purpose, commitment, courage, gratitude). This could be seen as an application of “positive psychology” since the focus is not on pathologizing questions but rather normalizing ones, in that they ask about “adversities that all people, including the clinician, frequently face” (e.g., “What kept you from giving up?”)

In the Hope vs Despair dimension, for example, there was a case cited of a 64-year-old man who was suicidal because he was facing mandatory retirement and for him his whole life had revolved around his work. He was helped by a three-month brief psychotherapy which included beginning with questions such as, “When did you last feel hopeful? What was that like? Which people in your life must help you to stay hopeful?” In the Agency vs Helplessness dimension, there was a case study of a young woman disturbed by early experiences of a dangerous neighborhood and the absence of reliable parents, who arrived at the initial session feeling helpless and defeated. Questions helpful in this situation include “When was a time when you knew that you were managing your life well, despite problems?; What should I know about you as a person that is not a part of your illness?; and How have you managed to keep these problems from taking total control of your life?”

Timing and careful attention in the observation, validating and normalizing of the patient’s experience are essential, “since resilience-building questions asked prematurely fall flat, regarded as naive efforts to solve tragic problems that are insolvable.” A moment of carelessness in the interviewing can thus undermine the therapeutic relationship and derail the treatment.

~ Rylan Dray, Ph.D. – August 2023

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