Demoralization as a Transdiagnostic Phenomenon Across the Lifespan: Definition, Differential Diagnosis, Treatment, and Future Directions

Background: Demoralization is a common transdiagnostic1 clinical phenomenon which presents with feelings of hopelessness, helplessness, and subjective incompetence, a perceived lack of social support, and loss of autonoetic consciousness. Studies suggest that up to one-third of patients in non-psychiatric medical settings and one-half of patients in psychiatric settings experience demoralization2,3. Demoralization is associated with an increased risk of suicide, poor treatment adherence, and a decline in quality of life. Despite its high prevalence and significant impact on health outcomes, demoralization is frequently unrecognized. Given this, and with no specific DSM criteria, it is critical that C-L psychiatrists identify and manage demoralization.

Approach: This workshop will utilize principles of adult-learning theory and multiple formats to engage participants including anonymous polling, breakout groups, peer-to-peer learning, didactic presentations, and self-directed reflection. Four clinical scenarios will be presented. The scenarios will feature patients with varying disease processes at varying stages of development to highlight the diversity of patients who experience demoralization. The workshop will be led by clinicians representing four different institutions.

Format:

1. 5 min, Audience polling: Dr. Kilciksiz will utilize Menti-polling to assess audience comfort in recognizing demoralization and solicit topics of audience interest.
   
2. 10 min, Presentation: Dr. Kilciksiz will provide a brief overview of demoralization as a diagnostic concept, its associated diagnostic criteria, and its relevance to C-L psychiatrists.
   
3. 20 min, Small Group breakout sessions: Each group will review one case and, led by our content experts, explore a series of related questions. One small group member will take notes to present later.
   
   
   
   1. Dr. Miran will present a young adult with cancer.
      
   2. Dr. Ramirez will present a middle-aged patient experiencing a prolonged medical admission including ICU stay.
      
   3. Dr. Stoklosa will present a young adult patient with newly diagnosed schizophrenia.
      
   4. Dr. Daniels will present an older patient with advanced cardiac disease.
      
      
   5. 40 min, Large Group discussion and presentations: Representatives from each small group will report the answers from their breakout session. Group leaders will provide a brief presentation discussing the approach to demoralization in their selected clinical population.
      
   6. 5 min, Final Summary: Dr. Kilciksiz will summarize and reinforce key points from the prior discussions.
      
   7. 10 min, Q&A and Audience Solo-write: Audience questions will be discussed. Audience members will be asked to share one key takeaway point in writing and via Menti-poll.
      
      

      Conclusion: Demoralization is a common clinical challenge across the lifespan and across disease processes. Multiple learning techniques will be utilized to assist audience members in learning to recognize demoralization, identify contributing factors, and develop a management approach.
      

      
      

      
      
      References:
      

      1) Gan LL, Gong S, Kissane DW. Mental state of demoralisation across diverse clinical settings: A systematic review, meta-analysis and proposal for its use as a 'specifier' in mental illness. Aust N Z J Psychiatry. 2022;56(9):1104-1129. doi:10.1177/00048674211060746
      
      2) Grassi L, Nanni MG. Demoralization syndrome: New insights in psychosocial cancer care. Cancer. 2016;122(14):2130-2133. doi:10.1002/cncr.30022
      
      3) Tecuta L, Tomba E, Grandi S, Fava GA. Demoralization: a systematic review on its clinical characterization. Psychol Med. 2015;45(4):673-691. doi:10.1017/S0033291714001597
      

      Learning Objectives:

      • Distinguish a diagnosis of demoralization from other primary psychiatric conditions including but not limited to major depressive disorder and adjustment disorder.
      • Formulate a differential diagnosis and treatment plan for patients experiencing existential distress in the setting of severe mental or physical illness.
      • Compare the relevant psychosocial risk factors for demoralization for patients across the lifespan.