Loss of resources and demoralization in the chronically ill.

OBJECTIVE: The study examined whether the association between the severity of physical symptoms and demoralization is mediated by loss of resources in individuals with chronic conditions including conventional diagnoses, functional somatic syndromes, and medically unexplained symptoms. METHOD: This cross-sectional study evaluated N = 194 patients (mean age = 46, 83.5% female) who reported at least 3 months of persistent physical symptoms using the following self-report instruments: PHQ-15 (modified), Loss of Resources Inventory, Psychosocial Questionnaire - Demoralization Subscale, and PHQ-8. The mediation hypothesis was tested by multiple regression analyses controlling for age, race, employment status, income, educational attainment, and depression. RESULTS: Participants experienced M = 9.3 out of 16 possible health-related losses (SD = 4.4). Average to severe demoralization scores were indicated by 59.1% of individuals, of which only 17.1% experienced high demoralization. Loss of resources fully mediated the effect of symptom severity on demoralization, explaining 56% of the variance of demoralization and inhibiting the initially significant effect of symptom severity on demoralization to nonsignificant levels [from b = 0.67, 95% CI (0.26, 1.07) to b = 0.03, 95% CI (-0.27, 0.32)]. CONCLUSION: Early recognition of the loss of resources phenomena and interventions to reduce its progression through the introduction of resource gains may diminish, or even prevent, the installation of demoralization in individuals with chronic symptoms.

Attachment security and existential distress among patients with advanced cancer.

BACKGROUND: Felt security in close relationships may affect individual adaptation responses to existential threat in severe illness. We examined the contribution of attachment security to demoralization, a state of existential distress involving perceived pointlessness and meaninglessness in advanced cancer. METHOD: A mixed cross-sectional sample of 382 patients with advanced cancer (mean age 59, 60% female) was recruited from outpatient oncology clinics. Participants completed self-report measures of attachment security, demoralization, depression, and physical symptom burden. We used multiple linear regression to analyze the association between attachment security and demoralization, controlling for demographic factors and symptom burden and tested whether attachment security moderated the association of symptom burden with demoralization. Separate analyses compared the contribution of the dimensions of attachment anxiety and attachment avoidance. RESULTS: The prevalence of clinically relevant demoralization was 35%. Demoralization was associated with lower attachment security (ß = -0.54, 95%CI: -0.62 to 0.46). This effect was empirically stronger for attachment anxiety (ß = 0.52, 95%CI: 0.44 to 0.60) compared to attachment avoidance (ß = 0.36, 95%CI: 0.27 to 0.45). Attachment security also significantly moderated the association of physical symptom burden with demoralization, such that with less attachment security, there was a stronger association between symptom burden and demoralization. CONCLUSION: Attachment security may protect from demoralization in advanced cancer. Its relative lack, particularly on the dimension of attachment anxiety, may limit adaptive capacities to deal with illness burden and to sustain morale and purpose in life. An understanding of individual differences in attachment needs can inform existential interventions for severely ill individuals.

Latent class analysis differentiation of adjustment disorder and demoralization, more severe depressive and anxiety disorders, and somatic symptoms in patients with cancer.

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.

The daily dynamics of loss orientation and life engagement in advanced cancer: A pilot study to characterise patterns of adaptation at the end of life.

Individual adaptation at the end of life may be characterised by how patients fluctuate in their orientation towards losses and death or engagement in meaningful activities in daily life. To describe these intraindividual patterns of change, we conducted a daily diary study over 7 days with 17 advanced cancer patients from in- and outpatient oncology and psycho-oncology clinics. Patients reported on the daily frequency of behaviours associated with loss orientation and life engagement using a standardised questionnaire. We characterised each patient's pattern of change with three parameters: the mean level (5-point-scale from 0 = never to 4 = always), mean fluctuation between successive days (MSSD) and the association between changes in loss and life orientation over time. We further explored the relationship between these patterns and free-text diaries. The daily assessment protocol was acceptable and feasible (46% participation rate, 97% diary completion rate). Individuals differed in mean levels of loss orientation (range: M = 0.1 to 2.7) and life engagement (M = 0.9 to 3.9), the degree of fluctuation (MSSD = 0.1 to 1.5 and MSSD = 0.3 to 0.9), and the correlations between these changes over time (r = -.83 to +.46), revealing distinctive intraindividual patterns. Further study of individual profiles in loss and life orientation can promote personalised balancing between facing "reality" and sustaining "hope" in end-of-life conversations.

One in two cancer patients is significantly distressed: Prevalence and indicators of distress.

OBJECTIVE: Psychological distress is common in cancer patients, and awareness of its indicators is essential. We aimed to assess the prevalence of psychological distress and to identify problems indicative of high distress. METHODS: We used the distress thermometer (DT) and its 34-item problem list to measure psychological distress in 3724 cancer patients (mean age 58 years; 57% women) across major tumor entities, enrolled in an epidemiological multicenter study. To identify distress-related problems, we conducted monothetic analyses. RESULTS: We found high levels of psychological distress (DT ≥ 5) in 52% of patients. The most prevalent problems were fatigue (56%), sleep problems (51%), and problems getting around (47%). Sadness, fatigue, and sleep problems were most strongly associated with the presence of other problems. High distress was present in 81.4% of patients reporting all 3 of these problems (DT M = 6.4). When analyzing only the subset of physical problems, fatigue, problems getting around, and indigestion showed the strongest association with the remaining problems and 76.3% of patients with all 3 problems were highly distressed (DT M = 6.1). CONCLUSIONS: Our results show a high prevalence of psychological distress in cancer patients, as well as a set of problems that indicate the likely presence of other problems and high distress and can help clinicians identify distressed patients even if no routine distress screening is available.

Detrimental social interactions predict loss of dignity among patients with cancer.

PURPOSE: This prospective study aimed to determine the extent to which cancer patients experience loss of dignity during primary cancer care (baseline) and at 3-month follow-up and the contribution of positive social support and detrimental social interactions on loss of dignity at follow-up. METHODS: At baseline, we enrolled N = 270 cancer patients (advanced cancer 57 %) undergoing oncological treatment. At follow-up, n = 178 patients (72 %) participated. Patients completed the following questionnaires: sense of dignity item (SDI), physical problem list of the NCCN Distress Thermometer, Illness-Specific Social Support Scale (SSUK), Patient Health Questionnaire (PHQ-9), and Generalized Anxiety Disorder Questionnaire (GAD-7). We conducted ordinal regression analyses controlling for age, gender, tumor stage, number of physical symptoms, depression, and anxiety. RESULTS: At baseline, 18 % of the patients experienced moderate to extreme loss of dignity (follow-up 23 %, p = 0.27). Detrimental interactions significantly predicted loss of dignity (OR = 1.42, 95 % CI 1.06-1.90) in a model including positive support (OR = 1.10, 95 % CI 0.82-1.49), depression (OR = 1.55, 95 % CI 0.96-2.51), and anxiety (OR = 1.20, 95 % CI 0.83-1.74). Items in relation to detrimental interactions with significant others such as "made you feel like you couldn't take care of yourself" (r = 0.29, p < 0.001) and "felt uncomfortable in illness conversations" (r = 0.24, p = 0.002) showed the highest associations with perceived loss of dignity. CONCLUSION: Loss of dignity was a frequent problem in our mixed cancer patient sample. Detrimental interactions that weaken the sense of dignity may result from discrepancies with patients' needs for autonomy and security. Tailoring social support to attachment-related patient needs may help to conserve patients' sense of dignity.

Anxiety and depression in long-term testicular germ cell tumor survivors.

OBJECTIVE: Despite a good prognosis, the typically young age at diagnosis and physical sequelae may cause psychological distress in germ cell tumor survivors. We aimed to determine the frequency of anxiety and depression and analyze the impact of demographic and disease-related factors. METHOD: We enrolled N=164 testicular germ cell tumor survivors receiving routine follow-up care at the University Cancer Center Hamburg and a specialized private practice (mean, 11.6 years after diagnosis). Patients completed the Generalized Anxiety Disorder Screener-7, the Patient Health Questionnaire-9 and the Memorial Symptom Assessment Scale-Short Form. RESULTS: We found clinically significant anxiety present in 6.1% and depression present in 7.9% of survivors. A higher number of physical symptoms and having children were significantly associated with higher levels of both anxiety and depression in multivariate regression analyses controlling for age at diagnosis, cohabitation, socioeconomic status, time since diagnosis, metastatic disease and relapse. Younger age at diagnosis and shorter time since diagnosis were significantly associated with higher anxiety. CONCLUSION: Although rates of clinically relevant anxiety and depression were comparably low, attention toward persisting physical symptoms and psychosocial needs related to a young age at diagnosis and having children will contribute to address potential long-term psychological distress in germ cell tumor survivors.

[Communication Bad News by Physicians: The German Version of the MPP (Measure of Patients' Preferences) Questionnaire to the Communicative Preferences of Cancer Patients]. / Die Mitteilung schlechter Nachrichten durch den Arzt: Die deutsche Version des MPP- (Measure of Patients' Preferences) Fragebogens zu den kommunikativen Präferenzen von Krebspatienten.

OBJECTIVES: Breaking bad news is as one of the most distressing tasks that doctors face with high demands on their communication and psychosocial skills. Patient preferences for communicating bad news influence the course of such consultations. The purpose of this study was to evaluate the psychometric characteristics of the German version of the Measure of Patients' Preferences (MPP), a questionnaire that has been validated in several international studies. METHOD: Statistical analyses were performed in a sample of N=270 cancer patients during early treatment phase (mixed cancer entities, mean age 56.9 years, 46.7% female). In this prospective study with 2 assessment times, the factorial structure of the MPP-D was examined using principal components analysis with varimax rotation. RESULTS: Factor analysis resulted in a 9-factor solution, the 3 factor structure of the original version was not replicated. Cronbachs α was>0.80 for 7 of the MPP-D subscales indicating good to excellent reliability. CONCLUSION: Further psychometric testing and optimisation of the measure is recommended.

Sources of meaning in cancer patients - influences on global meaning, anxiety and depression in a longitudinal study.

Although existential needs are highly prevalent in patients with cancer, specific sources of meaning have been little explored. We investigated whether specific sources of meaning predict global meaning and psychological distress. N = 258 patients with breast (45%), lung (39%) and gynaecological cancer (16%) completed a battery of validated questionnaires at T1. Six months later (T2), n = 183 (78%) patients participated again. The primary outcomes - sources of meaning, global meaning and psychosocial distress - were measured with the Sources of Meaning Profile-Revised (SOMP-R), Life Attitude Profile-Revised (LAP-R) and modules for depression and anxiety of the Patient Health Questionnaire (PHQ-9, GAD-7). Most important sources of meaning were 'engaging in personal relationships', 'preserving human values and ideals' and 'feeling financially secure'. Stepwise multivariate regression analyses controlling for demographic and medical factors revealed that 'engaging in personal relationships', 'preservation of culture and tradition' and 'interest in social and/or political causes' predicted lower depression. 'Leaving a legacy for the next generation' and 'feeling financially secure' predicted both higher depression and anxiety. The findings highlight the relevance of sources of meaning for the psychological well-being of cancer patients and point towards specific sources of meaning that should be focused in psychosocial interventions.