The European Journal of Psychiatry

Advances in the study of demoralization: An overview

Subtyping demoralization in the medically ill by cluster analysis

Background and Objectives: There is increasing interest in the issue of demoralization, particularly in the setting of medical disease. The aim of this investigation was to use both DSM-IV comorbidity and the Diagnostic Criteria for Psychosomatic Research (DCPR) in order to characterize demoralization in the medically ill. Methods: 1700 patients were recruited from 8 medical centers in the Italian Health System and 1560 agreed to participate. They all underwent a cross-sectional assessment with DSM-IV and DCPR structured interviews. 373 patients (23.9%) received a diagnosis of demoralization. Data were submitted to cluster analysis. Results: Four clusters were identified: demoralization and comorbid depression; demoralization and comorbid somatoform/adjustment disorders; demoralization and comorbid anxiety; demoralization without any comorbid DSM disorder. The first cluster included 27.6% of the total sample and was characterized by the presence of DSM-IV mood disorders (mainly major depressive disorder). The second cluster had 18.2% of the cases and contained both DSM-IV somatoform (particularly, undifferentiated somatoform disorder and hypochondriasis) and adjustment disorders. In the third cluster (24.7%), DSM-IV anxiety disorders in comorbidity with demoralization were predominant (particularly, generalized anxiety disorder, agoraphobia, panic disorder and obsessive-compulsive disorder). The fourth cluster had 29.5% of the patients and was characterized by the absence of any DSM-IV comorbid disorder. Conclusions: The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of demoralization as encompassed by the DCPR. Subtyping demoralization may yield improved targets for psychosomatic research and treatment trials.

Demoralization and the longitudinal course of PTSD following Hurricane Mitch

Background and Objectives: Numerous studies of disasters have used measures of non-specific distress as outcome measures. The utility of these measures as predictive of the long-term outcome of disasters has remained unclear, in particular the relationship with PTSD. This study examines whether demoralization is predictive and a useful concept to examine the long-term outcome of disaster related PTSD. Methods: The 1998 Hurricane Mitch that impacted Honduras was examined two-months (n = 800) and two-years following the disaster in a longitudinal community-based sample of 604 adults. Respondents were selected from a stratified sample in Tegucigalpa based on exposure and social economic status. PTSD diagnosed using the CIDI module at both periods of time. Demoralization was measured using the PERI-D at 2-months post-disaster. Results: The PERI-D, increased demoralization, was significantly associated with PTSD at two-month and two-years. In addition, increased demoralization was associated with increased risk of PTSD chronicity. Decreased demoralization was associated with PTSD remission. New onset PTSD was associated increased demoralization; however, the finding was not appreciated after controlling for potential confounders. Conclusions: Demoralization can be measured using a simple screening questionnaire that may be a useful in identifying individuals who may be at increased risk for PTSD in the short-term, as well as in the long-term following a disaster.

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 semi-structured 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.

Teaching medical students to recognize demoralization

Background and Objectives: Concepts such as demoralization fit well into Problem or Case-based learning methods that encourage students to organize knowledge based on clinical problems, rather than according to the disciplines of basic science. Methods: At two US schools, psychiatry clerkship students learn about demoralization and psychotherapy through structured, case based exercises that teach them to elicit and respond to patients´ life stories in ways that emphasize hope and empowerment. Results: Students´ reactions to these exercises, though mixed, suggest that they may enhance students´ understanding of the universal elements of distress (demoralization) that cut across many disabling conditions and of the role that caregivers may play in compounding or relieving this distress. Conclusions: Learning to recognize and respond to demoralization is an advanced communication skill that can be introduced during a psychiatry clerkship.

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.

Ambiguity at the crossroads of psychiatry and demoralization: Reflections and possibilities

Background and Objectives: The concept and the impact of Ambiguity in the complex field of all human transactions have been captured by the texture of Culture and its many faces across the world. It generates intense debates reaching even most if not all areas of Science, once considered an unchallengeable source of precision and clarity. This article deals with the role Ambiguity plays in contemporary Culture and in the current state of Medicine in general, and Psychiatry in particular, in spite of advances in basic, clinical and technology-based research and practice. Ambiguity affects psychiatric nosology, diagnosis, treatment, prognosis and outcome. Almost inevitably, Ambiguity leads to polarities, disagreements and conflict. Examples of each if these situations are presented. Not surprisingly, it also influences the emergence of Demoralization, a psycho-existential feature that, paradoxically can be both the acme of failure, and the pathway towards hope, an essential ingredient in the psychotherapeutic encounter. As the latter, Demoralization cannot be a "mental disorder", although its ambiguous nature contributes to a pervasive uncertainty. At the crossroads of Ambiguity, Psychiatry and Demoralization must look for a better level of communication as a way to lessen the impact of Ambiguity and make it not only a core, positive component of Psychiatry´s role but also a favorable ingredient in Demoralization´s effect on the trajectory of patienthood

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, non-specific 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.