‘Give-up-itis’ revisited: Neuropathology of extremis

Distinguishing and treating demoralization syndrome in cancer: A review

IMPORTANCE

Demoralization, characterized by a persistent inability to cope, as well as helplessness, hopelessness, and despair, is highly prevalent in oncology, with between 36% to 52% of patients exhibiting demoralization syndrome. Given established evidence linking demoralization in patients with cancer to physical symptom burden, quality of life, sleep disturbance, and suicidality, assessment and treatment of demoralization syndrome is critical for optimizing clinical and psychosocial outcomes.

OBSERVATIONS

The term "demoralization" is highly relevant to the care of patients with cancer facing life-limiting illnesses. Indeed, demoralization can be conceptualized as a feeling state characterized by the perception of being unable to cope with some pressing problems and/or of lack of adequate support from others. Despite a considerable overlap in symptoms, demoralization and depression should be regarded as distinct and independent clinical syndromes. Patients who are demoralized but not clinically depressed often describe a sense of subjective incompetence and do not report anhedonia (i.e., loss of interest and inability to enjoy things). Although the definition of demoralization is now included as a distinct syndrome in the International Classification of Diseases (ICD)-11, it has been neglected by the current U.S. official nosology in psychiatry, such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). As such, demoralization syndrome may be under- or misdiagnosed and treated ineffectively in the oncology setting, potentially prolonging suffering and influencing cancer outcomes.

CONCLUSIONS AND RELEVANCE

Optimization of methods to diagnose and assess demoralization syndrome is critical to underpin rigorous studies evaluating the efficacy of psychotherapeutic and pharmacological interventions for patients with cancer experiencing demoralization. Our review supports the use of specific diagnostic criteria for demoralization in cancer patients, introduces methodological considerations relevant to treatment studies, and presents a novel measurement approach to the assessment of demoralization severity with the Clinical Interview for Demoralization (CIDE).

Language, Time, and Death. An Ethico-Philosophical Perspective Following Hegel, Heidegger, Lévinas, and Blanchot

Our daily existence is affected by how we perceive death, be it our own’s death tocome or others’ death. The intimidating nature of death has the potential to affect our daily ethical existence in relation to the other, as is seen in various crises in human history. In such a context, since expansive literature in various approaches such as biological, sociological, psychological, and political addressing the question of death is already available, this essay presents an ethico-philosophical perspective on death and argues if death should be seen as the worst event that is to be experienced by being. In this essay, I correlate language, time, and death, contrasting popular analogies, i.e., death is possibility of impossibility (Hegel and Heidegger), and death is impossibility of possibility (Lévinas and Blanchot). Firstly, the essay stages the discussion with contrasting synchronic and diachronic perspectives of language, i.e., historical understanding of language and time in Hegelian terms and the messianic time in Lévinasian terms, to see how sensibility, i.e., universal meaning, is expressed through concept. Secondly, the essay sees how sensibility is expressed through a concept beyond dialectic opposition and negativity while acknowledging that the question of ethics arises only after the end of philosophy, for something is always inexpressible through expression; there is always remnant beyond philosophical significance. This essay not only argues language, time, and death as the ethical responsibility of the self towards the other, but also contributes to the understanding of language as ethics beyond philosophy, and death as passivity beyond ontology following Lévinas’s idea of messianic time and Blanchot’s views on literature and death.

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

OBJECTIVE

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.

METHOD

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.

RESULTS

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.

CONCLUSION

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.

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

OBJECTIVES

The 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.

METHODS

Ninety-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.

RESULTS

Depression, 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).

CONCLUSION

Early 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.

The relationship between demoralization and depressive symptoms among patients from the general hospital: network and exploratory graph analysis

INTRODUCTION

Depression and demoralization are highly prevalent among individuals with physical illnesses but their relationship is still unclear.

OBJECTIVE

To examine the relationship between clinical features of depression and demoralization with the network approach to psychopathology.

METHODS

Participants were recruited from the medical wards of a University Hospital in Italy. The Demoralization Scale (DS) was used to assess demoralization, while the Patient Health Questionnaire-9 (PHQ-9) to assess depressive symptoms. The structure of the depression-demoralization symptom network was examined and complemented by the analysis of topological overlap and Exploratory Graph Analysis (EGA) to identify the most relevant groupings (communities) of symptoms and their connections. The stability of network models was estimated with bootstrap procedures and results were compared with factor analysis.

RESULTS

Life feeling pointless, low mood/discouragement, hopelessness and feeling trapped were among the most central features of the network. EGA identified four communities: (1) Neurovegetative Depression, (2) Loss of purpose, (3) Frustrated Isolation and (4) Low mood and morale. Loss of purpose and low mood/morale were largely connected with other communities through anhedonia, hopelessness and items related to isolation and lack of emotional control. Results from EGA displayed good stability and were comparable to those from factor analysis.

LIMITATIONS

Cross-sectional design; sample heterogeneity CONCLUSIONS: Among general hospital inpatients, features of depression and demoralization are independent, with the exception of low mood and self-reproach. The identification of symptom groupings around entrapment and helplessness may provide a basis for a dimensional characterization of depressed/demoralized patients, with possible implications for treatment.

From Unpleasant to Unbearable-Why and How to Implement an Upper Limit to Pain And Other Forms of Suffering in Research with Animals

The focus of this paper is the requirement that the use of live animals in experiments and in vivo assays should never be allowed if those uses involve severe suffering. This requirement was first implemented in Danish legislation, was later adopted by the European Union, and has had limited uptake in North America. Animal suffering can arise from exposure to a wide range of different external and internal events that threaten biological or social functions, while the severity of suffering may be influenced by the animals' perceptions of their own situation and the degree of control they are able to exert. Severe suffering is more than an incremental increase in negative state(s) but involves a qualitative shift whereby the normal mechanisms to contain or keep negative states at arm's length no longer function. The result of severe suffering will be a loss of the ability of cope. The idea of putting a cap on severe suffering may be justified from multiple ethical perspectives. In most, if not all, cases it is possible to avoid imposing severe suffering on animals during experiments without giving up the potential benefits of finding new ways to cure, prevent, or alleviate serious human diseases and generate other important knowledge. From this it follows that there is a strong ethical case to favor a regulatory ban on animal experiments involving severe suffering.