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Objectives: Demoralization as a form of existential distress involves poor coping, low morale, hopelessness, helplessness, and meaninglessness. In a secondary analysis of a cohort of German cancer patients, we aimed to explore latent class structure to assess the contribution that symptoms of demoralization make to anhedonic depression, anxiety, adjustment, and somatic disorders., Methods: Measures of demoralization, depression, anxiety, physical symptoms, and functional impairment had been completed cross-sectionally by 1527 patients with early or advanced cancer. Latent class analysis used maximum likelihood techniques to define the unobserved latent constructs that can be predicted as symptom clusters. Individual patients were assigned to the most probable class. Classes were compared on demographics, and logistic regression assessed the odds of individual items predicting each class., Results: A 4-class model provided the best fit. Class 1 (n = 829, 54.3%) was defined by the absence of distress; Classes 2 to 4 all carried functional impairment. Class 2 (n = 333, 21.8%) was differentiated by somatic symptoms (sleep, tiredness, and appetite); Class 3 (n = 163, 10.7%) by anhedonia, anxiety, and severe demoralization; and Class 4 (n = 202, 13.2%) by adjustment and moderate demoralization. Members of Class 3 were more likely to be younger, female, anhedonic, depressed, and anxious. In both Classes 3 and 4, functional impairment, physical symptom burden, and suicidal ideation were present., Conclusions: In contrast with the severe symptom cluster carrying anhedonia, anxiety, and demoralization, the moderate symptom cluster was formed by patients with demoralization and impaired functioning, a clinical picture consistent with a unidimensional model of adjustment disorder., (Copyright © 2018 John Wiley & Sons, Ltd.)

Objective: To examine the psychometric properties of the Demoralisation Scale II (DS-II) and adapt it for use with women in the postnatal period., Background: Demoralisation is a psychological state characterised by a sense of incompetence and feelings of helplessness and hopelessness in response to a stressful situation. The postnatal period is a life stage of many disruptions. Women may lose their confidence and become demoralised if feeling unprepared for the tasks of motherhood. The DS-II is a 16-item scale developed among cancer patients, but with content that is also relevant postnatally, including items on sense of failure, helplessness, hopelessness, isolation, entrapment and loss of purpose., Methods: Rasch analysis was used to investigate the psychometric properties of the DS-II and refine the scale for postnatal use., Results: Participants were 209 women admitted with their babies to a residential early parenting programme. A 14-item revised scale was derived, the Postnatal DS-II, showing good psychometric properties, discriminant validity and sensitivity to change, and being well targeted to the sample., Conclusion: The Postnatal DS-II could have utility as an assessment tool, helping clinicians to understand better women's postnatal experiences, assess the effectiveness of interventions and communicate with women in a meaningful and non-stigmatising way.

A severe life threatening illness can challenge fundamental expectations about security, interrelatedness with others, justness, controllability, certainty, and hope for a long and fruitful life. That distress and suffering but also growth and mastery may arise from confrontation with an existentially threatening stressor is a long-standing idea. But only recently have researchers studied existential distress more rigorously and begun to identify its distinct impact on health care outcomes. Operationalizations of existential distress have included fear of cancer recurrence, death anxiety, demoralization, hopelessness, dignity-related distress, and the desire for hastened death. These focus in varying emphasis on fear of death, concern about autonomy, suffering, or being a burden to others; a sense of profound loneliness, pointlessness or hopelessness; grief, regret, or embitterment about what has been missed in life; and shame if dignity is lost or expectations about coping are not met. We provide an overview of conceptual issues, diagnostic approaches, and treatments to alleviate existential distress. Although the two meta-analyses featured in this special issue indicate the progress that has been made, many questions remain unresolved. We suggest how the field may move forward through defining a threshold for clinically significant existential distress, investigating its comorbidity with other psychiatric conditions, and inquiring into adjustment processes and mechanisms underlying change in existential interventions. We hope that this special issue may inspire progress in this promising area of research to improve recognition and management of a central psychological state in cancer care., (© 2018 John Wiley & Sons, Ltd.)

People with head and neck cancer (HNC) experience elevated symptom toxicity and co-morbidity as a result of treatment, which is associated with poorer psychosocial and quality-of-life (QoL) outcomes. This Phase I study examined whether an individualised mindfulness-based stress reduction (IMBSR) programme could be successfully used with HNC patients undergoing curative treatment. Primary aims were to explore feasibility, compliance, acceptability and fidelity. Secondary aims were to determine whether (1) participation in the intervention was associated with changes in post-intervention mindfulness and (2) post-intervention mindfulness was associated with post-intervention distress and QoL. Nineteen HNC patients participated in a seven-session IMBSR programme with pre- and post-test outcome measures of psychological distress, depression, anxiety and QoL. Primary aims were assessed by therapists or participants. Mindfulness, distress and QoL were assessed using self-report questionnaires at pre- and post-intervention. Longer time spent meditating daily was associated with higher post-intervention mindfulness. After controlling for pre-intervention mindfulness, there was an association between higher post-intervention mindfulness and lower psychological distress and higher total, social and emotional QoL. This study offers important preliminary evidence than an IMBSR intervention can be administered to HNC patients during active cancer treatment. A randomised controlled trial is warranted to confirm these findings., (© 2016 John Wiley & Sons Ltd.)

Advanced and progressive illnesses bring existential suffering to patients as an inevitable consequence of the disease and its treatment. Physicians need a typology of existential distress to aid its recognition and improved management. The major forms of existential challenge include (1) death anxiety, (2) loss and change, (3) freedom with choice or loss of control, (4) dignity of the self, (5) fundamental aloneness, (6) altered quality of relationships, (7) our search for meaning, and (8) mystery about what seems unknowable. An adaptive response to each challenge promotes equanimity, peace, and fulfillment while sustaining engagement with life, creativity, and joy. Physicians can do much to nurture courage and maintain each person's sense of meaning, value, and purpose.

Purpose: We showed in a companion paper that the prevalence of burnout among surgical oncologists at a comprehensive cancer center was 42% and psychiatric morbidity 27%, and high quality of life (QOL) was absent for 54% of surgeons. Here we examine modifiable workplace factors and other stressors associated with burnout, psychiatric morbidity, and low QOL, together with interest in interventions to reduce distress and improve wellness., Methods: Study-specific questions important for morale, QOL, and stressors associated with burnout were included in an anonymous Internet-based survey distributed to the surgical faculty at Memorial Sloan-Kettering Cancer Center., Results: Among the 72 surgeons who responded (response rate of 73%), surgeons identified high stress from medical lawsuits, pressure to succeed in research, financial worries, negative attitudes to gender, and ability to cope with patients' suffering and death. Workplace features requiring greatest change were the reimbursement system, administrative support, and schedule. Work-life balance and relationship issues with spouse or partner caused high stress. Strongest correlations with distress were a desire to change communication with patients and the tension between the time devoted to work versus time available to be with family. Surgeons' preferences for interventions favored a fitness program, nutrition consultation, and increased socialization with colleagues, with less interest in interventions conventionally used to address psychological distress., Discussion: Several opportunities to intervene at the organizational level permit efforts to reduce burnout and improve QOL.

Background: Burnout is a prevalent and important occupational hazard among surgical oncologists. The well-being or distress experienced can have a significant effect on clinicians and their families, the quality of care provided to patients, and the success of the health care organization., Methods: We aimed to measure the prevalence of burnout, psychiatric morbidity, and quality of life using standardized measures; characterize associated features; and ascertain the surgical faculty's views on potential interventions and obstacles to change. Additional questions about service commitment to well-being, use of annual leave, and attitudes about weekend surgical practice were constructed to guide future targeted interventions., Results: Among the 72 surgeons who responded (response rate of 73%), we found that 42% of surgeons reported burnout and 27% psychiatric levels of distress, while 30% used alcohol and 13% used sleep medications as a possible means to cope. Only one third of surgeons reported high quality of life across physical, emotional, spiritual, and intellectual domains., Discussion: Compared to general surgical practices, cancer surgeons achieved more personal fulfillment and made less use of distancing methods to cope with their patients. Institutional culture contributes to the nonuse of available annual leave, attitudes about weekend operating schedules, and missed opportunities for the leadership to attend to surgeons' well-being.

Introduction: Few couple-focused interventions have been developed to improve distress and relationship outcomes among men diagnosed with localized prostate cancer and their partners., Aims: We examined the effects of a five-session Intimacy-Enhancing Therapy (IET) vs. Usual Care (UC) on the psychological and relationship functioning of men diagnosed with localized prostate cancer and their partners. Pre-intervention levels of psychological and relationship functioning were evaluated as moderators of intervention effects., Methods: Seventy-one survivors and their partners completed a baseline survey and were subsequently randomly assigned to receive five sessions of IET or UC (no treatment). Eight weeks after the baseline assessment, a follow-up survey was administered to survivor and partner., Main Outcome Measures: Distress, well-being, relationship satisfaction, relationship intimacy, and communication were investigated as the main outcomes., Results: IET effects were largely moderated by pre-intervention psychosocial and relationship factors. Those survivors who had higher levels of cancer concerns at pretreatment had significantly reduced concerns following IET. Similar moderating effects for pre-intervention levels were reported for the effects of IET on self-disclosure, perceived partner disclosure, and perceived partner responsiveness. Among partners beginning the intervention with higher cancer-specific distress, lower marital satisfaction, lower intimacy, and poorer communication, IET improved these outcomes., Conclusions: IET had a marginally significant main effect upon survivor well-being but was effective among couples with fewer personal and relationship resources. Subsequent research is needed to replicate these findings with a larger sample and a longer follow-up., (© 2010 International Society for Sexual Medicine.)

Objective: To determine whether the prevalence of mental disorders and related factors increase as advanced cancer patients get closer to death., Method: Baseline, cross-sectional data from 289 patients who were assessed prior to their death as part of a multi-site, longitudinal, prospective cohort study of advanced cancer patients. Major depressive disorder, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-IV Axis I Disorders. Other factors examined included existential well-being, patient grief about their illness, physical symptom burden, terminal illness acknowledgment, peacefulness, and the wish to live or die., Results: Closeness to death was not associated with higher rates of mental disorders. Patients closer to death exhibited increased existential distress and physical symptom burden, were more likely to acknowledge being terminally ill, and were more likely to report an increased wish to die., Conclusion: Results do not provide support for the common clinical assumption that the prevalence of depressive and anxiety disorders increases as death nears. However, patients' level of physical distress, acknowledgment of terminal illness, and wish to die, possibly reflecting acceptance of dying, increased as death approached. Longitudinal studies are needed to confirm individual changes in rates of mental disorder as patients approach death., ((c) 2008 John Wiley & Sons, Ltd.)

The development and elaboration of a conceptualization of existential distress in patients with advanced disease is crucial in order to optimize our clinical response within palliative medicine. Demoralization is one expression of existential distress. Its empirical study will be greatly enhanced by a self-report measure that captures its dimensions and intensity. We report here on the development and testing of the Demoralization Scale in 100 patients with cancer. Factor analysis identified five relatively distinct dimensions: loss of meaning, dysphoria, disheartenment, helplessness, and sense of failure. These factors show high internal reliability, and convergent validity with the McGill Quality of Life Scale, Patient Health Questionnaire, Beck Depression Inventory, Beck Hopelessness Scale, Hunter Opinions and Personal Expectations Scale, and the Schedule of Attitudes toward Hastened Death. Its divergent validity is demonstrated through the differentiation of a subgroup of patients with high demoralization who do not meet DSM-IV categorization for a diagnosis of major depression. Confirmatory validation is needed for the scale to be used as a measure of change in interventions designed to treat demoralization.

Family Focused Grief Therapy (FFGT) is a new model of brief intervention, which is commenced during palliative care for those families shown to be at high risk of poor adaptation, and continued preventively into bereavement with the aim of improving family functioning and reducing the morbid consequences of grief. In this paper, baseline data on 81 families (363 individuals) selected by screening from a palliative care population are explored to confirm our previously reported observation that high levels of psychosocial morbidity are positively associated with worsening family dysfunction. The Family Relationships Index (FRI) was used for screening and the Family Assessment Device (FAD) as an independent family outcome measure. The Beck Depression Inventory (BDI), Brief Symptom Inventory (BSI) and Social Adjustment Scale (SAS) were the psychosocial measures. Families were classified according to their functioning based on the FRI. To allow for correlated family data, statistical analyses employed the generalized estimating equation (GEE) method, controlling for gender and depression (BDI). Screening of 257 families (701 individuals) revealed 74 (29%) well-functioning families and 183 (71%) at some risk of morbid outcome. Of the latter, 81 (44%) gave informed consent to enter a randomized controlled trial of FFGT. Patients had a mean age of 57 years, 51% were male and they suffered from cancer, with a median length of illness from diagnosis to death of 25 months. In accordance with the FFGT model, their family types were identified as Intermediate 51%, Sullen 26% and Hostile 23%. These were significantly associated with steadily increasing levels of distress (BSI) and poor social adjustment (SAS). The FAD confirmed the concurrent accuracy of the FRI. As significantly greater levels of psychosocial morbidity were present in families whose functioning as a group was poorer, support was generated for a clinical approach that screens for families rather than individuals at high risk. The predictive validity of the FRI as a screening measure was confirmed. Overall, these baseline data point to the importance of a family-centred model of care.

Hopelessness, loss of meaning, and existential distress are proposed as the core features of the diagnostic category of demoralization syndrome. This syndrome can be differentiated from depression and is recognizable in palliative care settings. It is associated with chronic medical illness, disability, bodily disfigurement, fear of loss of dignity, social isolation, and--where there is a subjective sense of incompetence--feelings of greater dependency on others or the perception of being a burden. Because of the sense of impotence or helplessness, those with the syndrome predictably progress to a desire to die or to commit suicide. A treatment approach is described which has the potential to alleviate the distress caused by this syndrome. Overall, demoralization syndrome has satisfactory face, descriptive, predictive, construct, and divergent validity, suggesting its utility as a diagnostic category in palliative care.

Background: Suffering threatens the integrity of the person, never more so in palliative care than when existential distress is left unaddressed., Objective: To describe a framework for considering existential distress, for use by the clinician, which includes issues of death anxiety, meaning of life, grief resulting from loss, isolation, loss of control and loss of dignity., Discussion: Each existential challenge operates across a spectrum of response from successful adaptation to morbid complication. Clinical responses to such predicaments and their complications described herein, are exemplified by the demoralisation syndrome and its treatment. Boundary violations that arise from a 'burnt out' clinician can be avoided. Our goal is to ameliorate suffering and help our patients accomplish a more peaceful journey during their dying.